Opportunities at WellMed , part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.

The Senior Claims Examiner is responsible for providing claims support to our teams in reviewing, analyzing, and researching complex health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. You\'ll need to be comfortable navigating across various computer systems to locate critical information. Attention to detail is critical to ensure accuracy which will ensure timely processing of the member\'s claim.

This position is full time. Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6am - 6pm CST. It may be necessary, given the business need, to work occasional overtime.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Review, process and identify medical claims based on standard operating procedures on CPS.

• Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates).

• Review and apply member benefit plans and provider contracts, Pricing, CMS rate letter, SCA’s etc. to ensure proper benefits and contract language is applied to each claim.

• Weekly/monthly goal of batches including meeting and maintaining a 95% quality standard and production standard of 90+ claims per day.

• Examine each claim for appropriate coding of CPT and ICD codes against charges that are billed and entered.

• Manually adjust pended escalated claims to resolve complex issues related to claim payments.

• Adjudicate complex medical provider-initiated claims using analytical/problem solving skills.

• Create and generate any overpayment documentation (notes in system, letter to typing) on all overpayments created by the examiner or any overpayments identified by examiner.

• Support implementation of updates to the current procedures and participate in new system updates and training.

• Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims errors/issues, using clear, simple language to ensure understanding.

• Ensures all claims reporting requirements are met; complete daily production reports and weekly pending reports.

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we\'re making health care work better for everyone.

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 / GED

• Must be 18 years of age OR older

• 2+ years of experience in metric-based environment (production, quality)

• 1+ years of experience processing medical, dental, prescription or mental health claims

• 1+ years of experience working in a fast-paced, high volume environment processing 50+ claims per day

• Proficiency with Microsoft Office Suite (Outlook, Word, Excel etc.)

• Ability to navigate and learn new and complex computer system applications

• Ability to work full time. Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6am - 6pm CST. It may be necessary, given the business need, to work occasional overtime.

Preferred Qualifications:

• Reside within commutable distance to 19500 W INTERSTATE, San Antonio TX 78257

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)

• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.

• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

Soft Skills:

• Proven exceptional ability to organize, prioritize and communicate effectively

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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 $20.00 - $35.72 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.

OptumCare is 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.

OptumCare is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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