POSITION DESCRIPTION

Let's talk about diplomacy. Let's talk about accuracy. Let's talk about how United Health Group became a Fortune 6 leader in healthcare. We did it by working to become an undisputed leader in creating service quality and helping to improve the lives of millions. Now, here's where you come in. You can build on your problem solving skills by taking on responsibility for reviewing, researching, investigating and triaging claims that were denied to determine their correct status. You'll drive the action and communicate with appropriate parties regarding appeals and grievance issues. In turn, we'll provide you with great training, support and opportunities. Works as a liaison between the Claims Department and the Health Plan to ensure all related issues are researched and responded to in a timely and efficient manner.

PRIMARY RESPONSIBILITIES:

• Responsible for researching and responding to all health plans claim issues received on the contractual arrangements of providers and the health plans in a timely manner
• Adjust claims as appropriate including calculation of interest and penalties due when applicable
• Reviews, researches and forwards new claims to the Claims Department for processing
• Maintain that health plan claims are processed in a timely manner
• Works with internal departments and health plans to gather information needed to ensure appropriate resolution
• Identify and forwards non-compliant providers to the Market Executive Director and / or staff, relating the referral of members to non-contracted providers without proper authorization
• Log and track those issues received from the health plans as identified by Supervisor
• Identify and report potential issues identified, to the attention of management, which may have an impact on the department's ability to follow established guidelines / policies
• Contacting providers to reiterate the stipulations of their contracts relating to incorrect billings to members (i.e., copays, balance billings, etc. )
• Identify, advise, and follow - up with configuration team regarding contract changes and system adjudication problems
• Foster interpersonal relationships, showing empathy and understanding towards staff, protecting individual self-esteem. Understand own impact on others; interact effectively with peers, subordinates, and supervisors
• Plan and organize workload to ensure efficient and timely resolution of issues
• Any other assigned duties and delegated by the Management

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.

• High school diploma or a general education degree
• 3 - 5 years of experience as a Claims Examiner with previous Medicare and HMO experience &/or experience with the system Configuration of Fee Schedules, Member Benefits packages, and Healthplan Risk arrangements.

PREFERRED QUALIFICATIONS:

• Working knowledge of medical terminology, ICD-9, CPT4 and HCPCs codes
• Working knowledge of UB92 and HCFA 1500 claim forms and FFS contract interpretation
• 2-3 years' experience of claims processing or billing environment a plus
• Working knowledge CMS (HCFA) and DMHC guidelines
• Extensive knowledge of HMOs Familiar with Knox Keene Act, Federal Register and Medicare Guidelines
• Ability to communicate effectively whether written or oral
• Excellent analytic skills needed
• Must be flexible, well organized, self - starter and a Team Player
• Revenue and HCPCS coding skillshelpful

CAREERS WITH OPTUM. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do YOUR LIFE'S BEST WORK.(SM)

NORTH AMERICAN MEDICAL MANAGEMENT, California, Inc. (NAMM) develops and manages clinician networks, offering a full range of services to assist physicians and other clinicians in their managed care and business operations. For over 17 years, NAMM has been an innovator in health care with a track record for quality, financial stability, extraordinary services and superior electronic capabilities. Prime Care Medical Network is a key affiliate.

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

A Fortune 6 company, we're focused on helping people live healthier lives while making the health system work better for everyone. Here, we seek to empower people with the information, guidance and tools to make personal health choices. We work harder and we aim higher. We expect more from ourselves and each other. And, at the end of the day, we’re doing a lot of good for more than 142 million people worldwide.