Senior Claims Examiner

UnitedHealth Group - San Antonio, TX

Full-time - Entry Level

Onsite - San Antonio, TX

Insurance Carriers and Related Activities

About the position

The Senior Claims Examiner plays a crucial role in providing claims support by reviewing, analyzing, and researching complex healthcare claims. This position ensures accuracy in processing claims, identifying discrepancies, verifying pricing, and confirming prior authorizations. Attention to detail is essential for timely processing, and the role requires navigating various computer systems to locate critical information.

Responsibilities

• Review, process and identify medical claims based on standard operating procedures on CPS.
• Apply appropriate processes and procedures to process claims, including claims processing policies and procedures, grievance procedures, state mandates, CMS / Medicare guidelines, and benefit plan documents.
• 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 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 and problem-solving skills.
• Create and generate overpayment documentation on all overpayments 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, using clear language to ensure understanding.
• Ensure all claims reporting requirements are met; complete daily production reports and weekly pending reports.

Requirements

• 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 in a fast-paced, high-volume environment processing 50+ claims per day
• 1+ years of experience processing medical, dental, prescription, or mental health claims
• Proficiency with Microsoft Office Suite (Word, Excel, Outlook)
• 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 the full-time, 8-hour shift schedules during normal business hours of 6:00 AM - 6:00 PM CST, with occasional overtime.

Nice-to-haves

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