Senior Claims Appeals & Adjustments Specialist

UnitedHealth Group; Pearland (TX); Remote; USD 28,000 - 50,000; Full time

Benefits offered by this job

Comprehensive benefits

Incentive programs

Equity stock purchase

401k contribution

Job summary

Kelsey-Seybold Clinic, part of the Optum family, invites you to join a team at one of our Houston-area locations. The position focuses on adjudicating complex medical and dental claims, collaborating with Customer Service, and ensuring accurate payments while adhering to guidelines.

You will review claim check guidelines, perform leakage analysis, and support monthly reconciliations. A strong knowledge of CPT/ICD coding and payor contracts is essential, along with five years of claims

Qualifications

• 5+ years of claims adjudication experience in a health plan environment.
• Focus on customer service and claims adjustments experience.
• Demonstrated understanding of payor contracts and reconciliation processes.

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.
• Initiate and report system/contract issues via TSU error log to TSU Team.
• Complete back out function for returned checks and refunds; document member history as needed.

Skills

Claims adjudication

Customer service

Regulatory knowledge

Medical terminology

CPT/ICD coding

Self-directed

Education

High School Diploma

Job description

Kelsey-Seybold Clinic, part of the Optum family, invites you to join a team at one of our Houston-area locations. The position focuses on adjudicating complex medical and dental claims, collaborating with Customer Service, and ensuring accurate payments while adhering to guidelines.

You will review claim check guidelines, perform leakage analysis, and support monthly reconciliations. A strong knowledge of CPT/ICD coding and payor contracts is essential, along with five years of claims