Job was saved successfully.
Job was removed from Saved Jobs.

Job Details

UnitedHealth Group

Senior, Claims Specialist- Payment Integrity


Clinical Care Specialist/Staff Nurse


El Segundo, California, United States

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

Responsible for processing, auditing, and adjusting all facility medical claims, appeals and prepayment audits. Answers incoming telephone inquiries, and accurately and thoroughly documents problems and resolutions. Troubleshoots claims that have been identified as needing additional work in the areas of eligibility, referral authorization and contracting or provider set-up. Trains and assists other analysts with problem claims and escalated telephone calls.

Primary Responsibilities:

  • Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer
  • Processes all types of medical claims and adjusts medical disputed claims (Professional and Facility) according to department, contract, and regulatory requirements
  • Performs prepayment audit on all types of medical claims (Professional and Facility) according to department, contract, and regulatory requirements
  • Answers telephone inquiries through the “Automated Call Distributor (ACD) Telephone System” as needed
  • Identifies individual provider needs and takes appropriate steps to satisfy those needs
  • Updates authorization information based on information obtained from provider
  • Troubleshoots problem claims to resolve provider issues or systematic issues
  • Verifies and interprets information in all vendor contracts to resolve issues
  • Trains analysts and monitors general office support functions as needed
  • Analyzes work processes, identifies areas needing improvements and initiates necessary steps to make changes
  • Participates in the continuous quality improvement of IMCS core business system
  • Follows unit procedures for performing call processing, claim adjustments and denials and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions
  • Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

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.

Required Qualifications:

  • High school diploma, GED or equivalent experience
  • 5+ years of experience in an indemnity and / or HMO setting processing, auditing or adjusting professional claims
  • Demonstrated solid proficiency using MS Suite and other systems
  • Professional working knowledge of CPT & Diagnosis Coding, Medical Terminology, and basic Anatomy
  • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

  • 1+ years of experience working in a healthcare setting
  • Experience in an indemnity and / or HMO setting processing, auditing, or adjusting facility claims
  • Bilingual

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.