Senior Claims Examiner

WellMed is part of OptumCare, a division under the greater UnitedHealthcare Group umbrella. We have a network of doctors, specialists and other medical professionals that specialize in providing the highest level of medical care for more than 1 million older adults with over 16,000 doctors' offices in Texas and Florida. We're growing, and we are making a difference by helping our patients achieve better health. With opportunities for physicians, clinical staff and non - patient - facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.

The Senior Claims Examiner is responsible for providing claims support to our teams in reviewing, analyzing, and researching complex health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. You'll need to be comfortable navigating across various computer systems to locate critical information. Attention to detail is critical to ensure accuracy which will ensure timely processing of the member's claim.

This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 6:00 AM - 6:00 PM CST. It may be necessary, given the business need, to work occasional overtime. Our office is located at 19500 W Interstate, San Antonio, TX, 78257.

Primary Responsibilities:

• Review, process and identify medical claims based on standard operating procedures on CPS.
• Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS / Medicare guidelines, benefit plan documents / certificates).
• Review and apply member benefit plans and provider contracts, Pricing, CMS rate letter, SCA's etc. to ensure proper benefits and contract language is applied to each claim.
• Weekly / monthly goal of batches including meeting and maintaining a 95% quality standard and production standard of 90+ claims per day.
• Examine each claim for appropriate coding of CPT and ICD codes against charges that are billed and entered.
• Manually adjust pended escalated claims to resolve complex issues related to claim payments.
• Adjudicate complex medical provider - initiated claims using analytical / problem solving skills.
• Create and generate any overpayment documentation (notes in system, letter to typing) on all overpayments created by the examiner or any overpayments identified by examiner.
• Support implementation of updates to the current procedures and participate in new system updates and training.
• Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims errors / issues, using clear, simple language to ensure understanding.
• Ensures all claims reporting requirements are met; complete daily production reports and weekly pending reports.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma / GED
• Must be 18 years of age OR older
• 2+ years of experience in a metric - based environment (production, quality)
• 1+ years of experience with working in a fast - paced, high - volume environment and processing 50+ claims per day
• 1+ years of experience with processing medical, dental, prescription, OR mental health claims
• Proficiency with Microsoft Office Suite (Microsoft Word, Microsoft Excel, Microsoft Outlook, etc.)
• Ability to navigate and learn new and complex computer system applications
• Reside within a commutable distance of 19500 W Interstate, San Antonio, TX, 78257
• Ability to work any of our full - time, 8-hour shift schedules during our normal business hours of 6:00 AM - 6:00 PM CST from Monday - Friday. It may be necessary, given the business need, to work occasional overtime.

Preferred Qualifications:

• 2+ years of experience with working in a fast - paced, high - volume environment and processing 50+ claims per day

Soft Skills:

• Proven exceptional ability to organize, prioritize, and communicate effectively

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.