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UnitedHealth Group - San Antonio, TX
posted 3 months ago
About the position
The Senior Claims Examiner plays a crucial role in providing claims support by reviewing, analyzing, and processing complex health care claims. This position ensures accuracy in claims processing, verifies pricing, confirms prior authorizations, and resolves discrepancies to facilitate timely payments. The role requires attention to detail and proficiency in navigating various computer systems to locate critical information, ultimately contributing to improved health outcomes for members.
Responsibilities
- Review, process and identify medical claims based on standard operating procedures.
- Apply appropriate processes and procedures to process claims, including claims processing policies and procedures, grievance procedures, state mandates, and CMS/Medicare guidelines.
- Review and apply member benefit plans and provider contracts to ensure proper benefits and contract language is applied to each claim.
- Meet weekly/monthly goals including maintaining a 95% quality standard and processing 90+ claims per day.
- Examine claims for appropriate coding of CPT and ICD codes against billed charges.
- Manually adjust pended escalated claims to resolve complex issues related to claim payments.
- Adjudicate complex medical provider-initiated claims using analytical and problem-solving skills.
- Create and generate overpayment documentation for claims identified by the examiner.
- Support implementation of updates to current procedures and participate in new system updates and training.
- Communicate and collaborate with external stakeholders to resolve claims errors/issues, ensuring clear understanding.
- Complete daily production reports and weekly pending reports to meet claims reporting requirements.
Requirements
- High School Diploma / GED
- 1+ years of experience processing medical, dental, prescription or mental health claims
- 1+ years of experience in a fast-paced, high volume environment processing 50+ claims per day
- 2+ years of experience in a metric-based environment (production, quality)
- Proficiency with Microsoft Office Outlook, Word, and Excel
- Ability to navigate and learn new and complex computer system applications
- Ability to work full time, Monday - Friday, with flexibility for 8-hour shifts during normal business hours.
Nice-to-haves
- Proven exceptional ability to organize, prioritize and communicate effectively.
Benefits
- Comprehensive benefits package
- Career development opportunities
- Diversity and inclusion culture
