WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

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.

The new hire is required to work the normal 8 hours. Operation hours are 6:00AM - 6:00PM CST.

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 6:00am - 6:00pm CST. It may be necessary, given the business need, to work occasional overtime. Our office is located at 19500 W. Interstate San Antonio, TX 78257.

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.

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
• 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
• 2+ years of experience in metric-based environment (production, quality)
• Proficiency with Microsoft Office Suite (Microsoft Outlook, Microsoft Word, Microsoft Excel etc.)
• Ability to navigate and learn new and complex computer system applications
• In commutable distance to 19500 W INTERSTATE, San Antonio TX 78257
• Must be 18 years of age OR older
• Ability to work full-time, Monday - Friday between 6:00am - 6:00pm CST including the flexibility to work occasional overtime given the business need

Preferred Qualifications:

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

Soft Skills:

• Proven exceptional ability to organize, prioritize and communicate effectively

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 #RED

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