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　　Position in this function supports claims administration which includes answering incoming telephone inquiries and accurately and thoroughly document problems and resolutions. Processes simple hospital claims for payment denial, or referral for the appropriate payor, and troubleshoots claims that have been identified an needing additional work in the areas of eligibility referral/authorization, contracting and/or provider set-up.

　　Bring your claims experience to our team! If you’re a flexible team player with a background in claims processing and/or adjustment, you might be the our Hospital Claims Examiner that we’re looking for to complete our dedicated team of professionals. In this detailed, research-based position, you would be processing hospital claims and deciding if they should be paid or denied.

　　Primary Responsibilities:

　　Receiving electronic reports and reviewing the accurate payment criteria to decide whether to pay or deny the claim

　　Managing aging claims and meeting tight deadlines

　　Meeting quality and production standards

　　Learning how to do adjustments and serving as a back-up for processing adjustments when needed

　　Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer

　　Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

　　Follows unit procedures for performing call processing, claim adjustments and details and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions

　　Answers telephone inquiries through the Automated Call Distributor (ACD)

　　Troubleshoots claims that require an authorization; tracks progress of resolution of claims issues and routes resolved claims back to the appropriate claims resource

　　Processes simple HCFA claims and performs simple claims adjustments as needed

　　Identifies individual provider needs and takes appropriate steps to satisfy those needs

　　Participates in continuous quality improvement of IMCS core business system

　　Performs 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:

　　Experience in Hospital/Facility claims processing

　　Experience with revenue codes

　　Experience ICD-10

　　Familiar with HMO guidelines

　　Knowledge of Microsoft Office products

　　Knowledge of compliance related to the processing of claims

　　Ability to research and verify claim payment issues

　　Ability to work for a Hybrid role (3 days in our San Jose office and 2 days remote)

　　Ability to work 7am-3:30pm PST

　　Preferred Qualifications:

　　1+ years of experience in an indemnity and/or HMO setting

　　Knowledge of all types of hospital claims

　　Knowledge of medical terminology and pricing options

　　Knowledge of different sources of authorization documentations

　　Proven ability to work in an environment with fluctuating workloads

　　Proven ability to solve problem systematically, using sound business judgement

　　Proven ability to make decisions with every call and handle escalated issues

　　Proven ability to make decisions regarding escalation of referrals to Care Management

　　Proven ability to read and interpret all vendor contracts

　　California Residents Only: The hourly range for California residents is $19.47 to $38.08 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

　　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.

　　Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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