Claims Appeals & Adjustments Analyst — Equity Eligible

Optum; Pearland (TX); On-site; USD 28,000 - 50,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

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

Qualifications

• 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.

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 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.

Skills

Customer service

Claims adjudication

Regulatory compliance

HIPAA knowledge

Education

High School Diploma or equivalent

Business course (3 months)

10Key by touch

Typing 30 wpm

Tools

EDI reconciliation

Job description

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