Claims Appeals & Adjustment Analyst -Remote - Kelsey Seybold

Optum; Pearland (TX); Presencial; USD 28.000 - 50.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Descripción de la vacante

Optum, in Pearland, TX, is seeking a Claims Adjudication professional to adjudicate complex medical/dental claims and support adjustments through CSR processes. You will review provider issues and member reimbursements, apply claim guidelines, and assist with monthly leakage analyses.

The role emphasizes accuracy, collaboration with Customer Service, and adherence to regulatory guidelines. A strong background in payor contracts and EDI is preferred, with growth opportunities within a national

Formación

• High School Diploma or equivalent.
• 5+ years of claims adjudication experience in an HMO, PPO, or TPA environment.
• Focus on Customer service and claims adjustments experience.
• Solid knowledge of payor contracts, provider/health plan reconciliation, and EDI reconciliation.
• Understanding of medical terminology, CPT and ICD9 Coding and billing forms (HCFA/UB92).
• Ability to understand regulatory guidelines (SB418, HIPAA).
• Ability to interpret contracts, fee schedules and reimbursement methods.
• Self directed and quick learner.

Responsabilidades

• Determine adjudication status based on audit review software.
• Perform claims adjustments initiated by providers, customer service requests and health plans.
• Conduct pre/post analysis of high dollar payments and leakage reconciliation tasks.
• Report system/contract issues via TSU error log to TSU Team; complete special projects.
• Complete back out function for returned checks and refunds; document member history.

Conocimientos

Customer service

Claims adjudication

Regulatory compliance

HIPAA knowledge

Educación

High School Diploma or equivalent

Business course (3 months)

10Key by touch

Typing 30 wpm

Herramientas

EDI reconciliation

Descripción del empleo

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.

Position in this function is responsible for the adjudication of complex medical/dental claims while maintaining minimum requirement for production and accuracy. Essential job functions include effectively working closely with Customer Service representatives to complete request for claims adjustments through the CSR module. Review and interpret provider issues and member reimbursements for payment. Review of Claim Check guidelines and apply guidelines to claim payment. Perform departmental research necessary for monthly leakage reconciliation received from the health plans. Conduct pre/post analysis of high dollar payments and present summary to management. Review of returned checks and perform back out process of both provider return checks and refunds received; document member history as needed. Perform post provider audits, complete all provider adjustments, and complete provider invoices received.

Primary Responsibilities

• Determine adjudication status based on audit review software
• Perform claims adjustments initiated by providers, customer service requests and health plans
• Conduct pre/post analysis of high dollar payments, perform leakage reconciliation tasks
• Initiate and report system /contract issues via TSU error log to TSU Team. Complete special projects, perform research of claims inquiries and claims correspondence. Identify incorrect payment trends via claims adjustment process and provider to trainer and supervisor
• Complete back out function for returned checks and refunds received. Perform 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 or equivalent
• 5+ years of claims adjudication experience in a HMO, PPO, or TPA environment
• Focus on Customer service and claims adjustments experience
• Demonstrate solid working knowledge of payor contracts, provider/health plan reconciliation process, and EDI reconciliation process
• Demonstrated understanding of medical terminology, CPT and ICD9 Coding and billing forms (HCFA/UB92)
• Ability to understand and/or interpret regulatory guidelines (i.e. SB418, HIPAA, etc..)
• Proven ability to interpret and apply contracts, fee schedules and reimbursement methods
• Proven self directed and able to absorb new material quickly

Preferred Qualifications

• 3+ years experience as Claims Payment Analyst with KSC and demonstrated ability to process complex medical claims
• 3 month course in business school
• 10Key by touch 8,000 keystrokes
• Typing (30 wpm)

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $20 - $36 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.