The health care system is still evolving at a rapid pace. Technology is driving new advances in how patient care is delivered and how it's reimbursed. Now, UnitedHealth Group invites you to help us build a more accurate and precise approach to claims adjudication. In this role, you'll be responsible for the implementation and day to day performance of process activities related to claims research and resolution. This includes the review of claims, contracts, and fee schedules to identify processing, procedural, systemic and billing errors. Join us and build your career with an industry leader.

PRIMARY RESPONSIBILITIES:

• Responsible for performing research and analysis to facilitate the resolution of provider / member claims issues based on regulatory requirements
• Performs complex and extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers, members and health plans Conducts necessary follow-up with internal departments within set timeframes to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration
• Acts as a department resource and gives support to Customer Service and researches Practice Connect issues for resolution. Responds to provider calls related to provider disputes and appeals for incoming provider / member disputes
• Identify, trend, and report the Provider Dispute and Resolution process for Monarch Healthcare management and prepare reports for management summarizing observations and recommendations for quality improvement
• Provides qualified data to the Business Operations Compliance & Regulatory Manager for incorporation into training programs and policies and procedures. Confers with management to assess training needs in response to identified trends
• Collaborates with other departments and management to implement and reinforce policy quality standards

REQUIRED QUALIFICATIONS:

• Associates degree (A.A.) or related experience
• 2+ years related experience in the following areas:
  • Claims processing
  • Compliance and regulatory governing agencies (CMS, DMHC, DHS)
  • Provider dispute and resolution process (AB1455)
  • Provider appeals
  • Correct Coding Initiatives (CCI edits)
  • Contract language interpretation
  • Healthplan eligibility
  • Health Care Benefits

PREFERRED QUALIFICATIONS:

• Knowledge of HCFA-1500 and UB-92 claim forms
• Intermediate skill levels in Microsoft Word, Excel, Access, and Outlook
• Ability to operate general office equipment, i.e. fax, copier

What's the first thing that happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do YOUR LIFE'S BEST WORK.(SM) 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.