Claims Quality/Audit Representative - Remote In Ca

If you are located within the State of California, you will have the flexibility to telecommute* (work from home) 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, Monday - Friday. Employees are required to work our normal business hours of 8:00am – 4:30pm PST. It may be necessary to work weekends as needed for special projects. Our office is located at 2304 Zanker Rd, San Jose, CA 95131.

• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

The following are exemplary essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position:

• Responsible for all aspects of quality assurance from a sample of random claims, check run reviews and Health Plan audits.
• Provide expertise and support by reviewing, researching, investigating, and auditing problematic claims.
• Analyze and identify trends and provide feedback and reports to reduce errors and improve claims processes and performance.
• Disseminate QA information/findings to claims staff in a timely manner in a clear and professional manner.
• Work with Claims Trainer to identify, document, and propose solutions for areas of variations from the norm, or potential high-risk areas requiring further one-on-one or group training.
• Work with the Claims Regulatory Compliance Data Analyst to coordinate workflows related to the completion of Health Plan audits.
• Maintain worksheets that support the overall details of the QA program within the Claims Department.
• Provide the Director of Claims and Team Leaders with timely detailed monthly reports that outline departmental and individual statistical results as requested.
• Support the claims department by reviewing procedural documentation on claims processing as they relate to QA reviews. Provide recommendations based on findings.
• Perform other duties as directed to support claims functions, which are focused on achieving both departmental and organizational objectives.
• Direct and coordinate discrepancies to supporting internal departments by providing details of configuration issues that have caused system inadequacies.
• Coordinate with all departments (i.e.: Eligibility-Benefits, Managed Car Revenue and Network Management/Contracting and Finance and others) to ensure accurate information is in the system on a progressive basis.

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 working in a Healthcare Managed Care environment.
• 2+ years of experience in reviewing Claims Adjudication data
• Must be proficiently skilled in the application and use of Windows, Microsoft Word, Microsoft Excel, and Microsoft Outlook.
• Ability to work 8:00am-4:30pm PST. It may be necessary to work weekends as needed for special project

Preferred Qualifications:

• Knowledge of CPT, RBRVS, ICD-10 coding, ASA, PDR, and regulatory requirements set forth by the DMHC, CMS and DHS agencies.
• Knowledge and experience of DRG, APC, & ASC claim pricing.
• Knowledge of health plan requirements for claims processing.
• Quality assurance program experience
• Must have knowledge of eligibility, benefits, copays, deductibles, and claims examining theory.
• Experienced in Health Plan and Vendor contract interpretation.
• Experience with HIPAA Regulation and California State Laws.

Telecommuting Requirements:

• Reside within the State of California.
• 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:

• Excellent verbal, written and interpersonal communication skills required.
• Ability to multi-task in an efficient, thorough, and prioritized manner; to work quickly, accurately, and independently; and, to anticipate needs and solve problems.
• Work with a spirit of enthusiasm, teamwork, cooperation, and a sense of urgency, and maintain a high degree of confidentiality over all matters in the course of business operations.
• Strong people skills and effective communication skills.

California Residents Only: The hourly range for California residents is $16.54 - $32.55 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: 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.

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