Senior Claims Examiner - San Antonio, TX

United Healthcare Services - San Antonio, TX

Full-time - Entry Level

Onsite - San Antonio, TX

Professional, Scientific, and Technical Services

About the position

The Senior Claims Examiner at United Healthcare Services Inc. is responsible for reviewing, analyzing, and processing complex health care claims to ensure accuracy and compliance with established procedures. This role requires attention to detail and the ability to navigate various computer systems to identify discrepancies and verify claims for payment. The position is full-time, with a focus on meeting quality and production standards while collaborating with external stakeholders to resolve claims issues.

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.
• Meet weekly/monthly goals including 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 on all overpayments created by the examiner or identified by the 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.
• Ensure all claims reporting requirements are met; complete daily production reports and weekly pending reports.

Requirements

• High School Diploma / GED
• 1+ years of experience processing medical, dental, prescription or mental health claims
• 1+ years of experience working in a fast-paced, high volume environment processing 50+ claims per day
• 2+ years of experience in metric-based environment (production, quality)
• Proficiency with Microsoft Office Outlook
• Proficiency with Microsoft Office Word
• Proficiency with Microsoft Office Excel
• Ability to navigate and learn new and complex computer system applications
• Ability to work full time, Monday - Friday, with flexibility to work any of the 8-hour shift schedules during normal business hours of 6:00am - 6:00pm CST.

Nice-to-haves

• Proven exceptional ability to organize, prioritize and communicate effectively

Benefits

• Comprehensive benefits package
• Career development opportunities
• Diversity and inclusion culture