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Job Details

Claims Specialist I


Clinical Care Specialist/Staff Nurse


El Segundo, California, United States

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Position in this function supports claims administration which includes answering incoming telephone inquiries and accurately and thoroughly document problems and resolutions. Processes simple professional medical claims for payment denial, or referral for the appropriate payor, and troubleshoots claims that have been identified an needing additional work I the areas of eligibility referral/authorization, contracting and/or provider set-up.

Primary Responsibilities:

  • Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer
  • Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
  • Follows unit procedures for performing call processing, claim adjustments and details and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions
  • Answers telephone inquiries through the Automated Call Distributor (ACD)
  • Telephone System; updates authorization information based on information obtained from caller; and ensures the average call monitor score over the previous six months meets or exceeds quality standards
  • Troubleshoots claims that require an authorization; tracks progress of resolution of claims issues and routes resolved claims back to the appropriate claims resource
  • Processes simple HCFA claims and performs simple claims adjustments as needed
  • Identifies individual provider needs and takes appropriate steps to satisfy those needs
  • Participates in continuous quality improvement of IMCS core business system
  • Performs other duties as assigned

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, G.E.D. or equivalent
  • Includes special certification for specific jobs
  • 1+ years of business related experience
  • Experience in Hospital/Facility claims processing

Preferred Qualification:

  • 1+ years of experience in an indemnity and/or HMO setting

Knowledge, Skills and Abilities:

  • Knowledge of Microsoft Office products
  • Individual must be reliable, dependable, and punctual
  • Excellent customer service and telephone skills
  • Excellent verbal and written communication skills
  • Ability to work in an environment with fluctuating workloads
  • Ability to solve problem systematically, using sound business judgement
  • Ability to make decisions with every call and handle escalated issues
  • Ability to make decisions regarding escalation of referrals to Care Management
  • Familiarity with ICD-9 and CPT codes
  • Knowledge of all types of professional claims
  • Ability to research and verify claim payment issues
  • Knowledge of compliance related to the processing of claims
  • Knowledge of medical terminology and pricing options
  • Knowledge of different sources of authorization documentations
  • Ability to read and interpret all vendor contracts

Physical Requirements:

  • Carrying/Lifting: Occasional / 0-10 lbs
  • Standing: Occasional / Up to 3 hours per day
  • Sitting: Constant / Up to 8 hours per day
  • Walking: Occasional / Up to 3 hours per day
  • Repetitive Motion: Keyboard activity, telephone use, writing
  • Visual Acuity: Ability to view computer monitor and read newsprint with or without corrective lenses
  • Environmental Exposure: None

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California Residents Only: The hourly range for California residents is $16.00 to $31.44. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.