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

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

This position is full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6:00am - 6:00pm Pacific Time. It may be necessary, given the business need, to work occasional overtime.

We offer 1 week of paid training. The hours during training will be 7:00am to 3:30pm PST, Monday - Friday. Training will be conducted virtually from your home.

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Primary Responsibilities:

• Review written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers regarding either Professional or Institutional Claims
• Interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers
• Adjust claims, as appropriate, including calculation of interest and penalties due when applicable
• Utilize a determinant engine within claims platform application to select batches of mass various quantities of claims for reprocessing
• Review claims output queries for various batch reprocessing requests where mass re-adjudication of claims needed for under and overpaid claims
• Identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
• Plan and organize workload to ensure efficient and compliance resolution of issues
• Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
• Responsible for requesting special check run requests to insure compliance
• Warning reports are monitored daily to insure compliance
• Provider education calls completed based on outcomes of PDR
• Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455
• Maintain minimum standards set for the department for quality and quantity of appeals received
• Update Provider Dispute Database with the outcome resolution of issues as appeals are completed
• Responsible for keeping Team Supervisor aware of potential problem issues for our education to all departments involved with claim issues. Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers
• Any other assigned duties and delegated by the Management

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
• 2+ years of experience as a Claims Examiner and/or appeals representative with previous Medicare and HMO
• 2+ years of experience adjudicating both professional and facility type of claims
• 1+ years of experience working appeals
• Experience effectively interpreting provider contract language and provisions
• Working knowledge of medical terminology, ICD9, ICD 10, CPT4, HCPCs
• Working knowledge of UB04 and CMS 1500 Forms
• Extensive HMO knowledge
• Knowledge of AB1455, Knox Keene Act, Federal Register and Medicare Guidelines and Regulations
• Working knowledge of Revenue and HCPCS coding practices
• Intermediate/Advanced Proficiencies in Microsoft Excel, and Microsoft Access
• Must be 18 years of age OR older
• Ability to work full-time, Monday - Friday between 6:00am - 6:00pm Pacific time including the flexibility to work occasional overtime given the business need

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:

• Ability to communicate effectively
• Excellent grammatical and letter writing skills; in adherence to regulatory guidelines
• Excellent analytic skills
• Flexible, self-starter, team player
• Able to work independently and solve moderately complex issues with limited supervision

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Washington or Rhode Island Residents Only: The hourly range for this is $19.47 - $38.08 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

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.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer 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.

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

#RPO

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