Vacancy expired!
PrimaryResponsibilities:
Provide expertise or general claimssupport by reviewing, researching, investigating, negotiating, processing andadjusting claims
Authorize appropriate payment orrefer claims to investigators for further review
Requestand follow-up on additional information as needed for incomplete claims.
Analyze and identify trends andprovides reports as necessary
Consistently meet establishedproductivity, schedule adherence, and quality standards
Provide excellent customer service
Accurately process professionalclaims
Responsible for editing andadjusting of claim per the EDI daily audit report
Analyze and adjudicate claims toensure accurate payment
Interpret Fee for Service (FFS) andcapitated provider contracts
Review claims on a periodic basis
Meet Department Quality and AccuracyStandards
RequiredQualifications:
1+ years’ healthcare/medical ClaimsExaminer experience
3+ years of experience analyzing andsolving customer problems in an office setting environment using the telephoneand computer as the primary instruments to perform job duties
Moderate Proficiency with computerand Windows PC applications, which includes the ability to learn new andcomplex computer system applications
PreferredQualifications:
An education level of at least ahigh school diploma or GED
Experience working on claims in aManaged Care setting.
Ability to multi-task, this includesability to understand multiple products and multiple levels of benefits withineach product
Demonstrates excellent interpersonalskills as discerned through observation and team project successes.
Accurately interprets and appliesdepartmental policies and procedures using sound judgment as is related toclaims processing.
OptumCare is committed to creating an environment where physicians
focus on what they do best: care for their patients. To do so, OptumCare
provides administrative and business support services to both owned and
affiliated medical practices which are part of OptumCare. Each medical practice
part and their physician employees have complete authority with regards to all
medical decision-making and patient care. OptumCare’s support services do not
interfere with or control the practice of medicine by the medical practices or
any of their physicians.NorthAmerican Medical Management , California, Inc. (NAMM) develops and manages clinician networks,
offering a full range of services to assist physicians and other clinicians in
their managed care and business operations. For over 17 years, NAMM has been an
innovator in health care with a track record for quality, financial stability,
extraordinary services and superior electronic capabilities. Prime Care Medical
Network is a key affiliate.Diversitycreates a healthier atmosphere: OptumCare is an Equal EmploymentOpportunity/Affirmative Action employers and all qualified applicants willreceive consideration for employment without regard to race, color, religion,sex, age, national origin, protected veteran status, disability status, sexualorientation, gender identity or expression, marital status, geneticinformation, or any other characteristic protected by law.OptumCareis a drug-free workplace. Candidates are required to pass a drug test beforebeginning employmentJob Keywords: Claims Examiner,
Ontario, CA, California, Medicare, compliance, healthplans, CMS, DHMC, ICD10,
Form 1500, HCPCS
Vacancy expired!