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Healthcare Claims Auditor (Data Mining) - San Juan, PR


Clinical Data Management


San Juan, Puerto Rico, 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.

If you want to achieve more in your mission of health care, you have to be really smart about the business of health care.

This role performs audit process activities related to Audit and Recovery programs. The incumbent will review production audits including but not limited to, contracts, fee schedules, coordination of benefits, client specific systems, procedural documentation associated with the assigned work. The incumbent will review ad hoc audits, client referrals and test new audits in development. The objective is to identify identifying claim overpayments from claims paid data, identify changes in data and audits and make recommendations for solutions and improved results.

Primary Responsibilities:

  • Demonstrating proficiency on assigned audits, handle ad hoc audits and referrals, associated systems and policies
  • Perform complex claims analysis, identify trends and root causes of payment inaccuracies
  • Production and quality metrics along with defined turnaround times are achieved on an ongoing basis
  • Ensure all audit results are supported by documentation, contract, state and client compliance is followed
  • Audit findings are documented and submitted according to standard practices for the client
  • Auditors are expected to understand all payment methodologies/claim benefits and be able to calculate overpayments that will be communicated to a provider
  • Maintain any databases and spreadsheets related to assigned work
  • Communicating to their manager any issues impeding progress of goals and suggesting solutions to meet and exceed expectations
  • Work collaboratively with all internal and external parties
  • Monitor and manage all aspects of assigned responsibilities by organizing, planning and tracking assigned tasks and priorities to ensure financial and client service level commitments are exceeded
  • Research relevant systems and documentation and solve for open issues such as contract documentation and discrepancies
  • Support the overall team objectives. A responsibility of this role is to continually look for new opportunities in data they are reviewing and to seek and suggest process improvements


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:

  • Associate’s Degree or higher Degree completed
  • 2+ years of experience in the healthcare industry
  • 1+ years of experience processing/applying Medicaid and Medicare policies
  • 1+ years in an audit environment
  • Knowledge with at least 1 claim platform or similar operating system technology
  • Knowledge analyzing large sets of data to identify mispaid claims, identify trends/root causes, payment processes, methodologies and policies
  • Proficient in MS Office with strong computer skills (e.g. multiple systems experience, keyboarding skills, trouble-shooting IT concerns, Microsoft Excel, MPP, Microsoft Project, OneNote)
  • English Proficiency (verbal and written)

Preferred Qualifications:

  • Certified professional coder
  • Information Technology Certifications
  • Six Sigma experience/Lean experience
  • Knowledge of managed care and government operations/products
  • Knowledge in SQL/Macros/Data Bases

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. 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.

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.