This position is responsible for accurate and prompt payment of claims, in addition to reporting of statistics / data and handling complex claims pricing methodology. The Senior Claims Examiner functions as a subject matter expert, and provides guidance to Claims Examiners on more complex issues. Examiners are responsible for adjudication of all claims. Examiners are responsible for handling customer service calls as needed, recalculating claims on an as needed basis. Examiners will be expected to maintain production and quality standards. Primary Responsibilities:Coordinates with the Claims Manager and / or Claims Supervisor on workflow issues and the handling of batches in date orderDocuments all claims production via the system BA screen (which tracks individual examiner production). Online transactions to be tracked separatelyResponsible for weekly / monthly goal of batches to include meeting and maintaining a 95% quality standard and production standard of 35 claims per hour on transactionsEvaluates each claim for appropriate coding of CPT and ICD codes against charges that are being billed and enteredResponsible for inputting accurate batch accounts, invoice numbers, status codes to ensure accurate entry into Claims Processing system, which creates reportingMust meet and maintain 95% quality expectations. These are identified via errors tracked on phone calls, overpayments, unsolicited checks, appeals, TDI complaints and errors on processingResponsible to create and generate any overpayment documentation (notes in system, letter to typing) on all overpayments created by the examiner or any overpayments identified by examinerTakes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfactionPerforms all other related duties as assigned
Required Qualifications:High School Diploma or GED2 - 4 years of health care claims processing experienceMedical Terminology, 10-key and computer literacyProficient with Medicare processing guidelines, working knowledge of medical contracts, RBRVS, facility and ambulatory payment methodologiesExceptional ability to organize, prioritize and communicate effectivelyMust have commonly used knowledge of claims examination concepts, practices and rules, ICD and CPT coding and network contractsThis position utilizes experience and judgment to plan, accomplish goals, and effectively solve problemsAbility to make decisions based on sound knowledgePerforms a variety of tasks that may require a limited degree of creativity and latitude Preferred Qualifications: More than 5 years of related experienceAdvanced training in claims processesPrevious claims examiner experience Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm) 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.
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.