Under the general direction of the VP of Claims/ Coding this position is responsible for the day- to- day supervision of the staff that performs claims review, and/or resolution of claims issues for all types of claims. In addition, this position will be responsible for leading both focused and routine reviews, review and communication of high- profile claims issues for specific providers, hospitals and ASC to review coding and documentation and reporting results of said functions, as well as other functions as necessary. This position has oversight of any external audits as well as for input to and adherence to the Claims Review annual plan.
Primary Responsibilities:
- Monitors and document all totals related to claims payment errors and examiner productivity for reporting purposes as established in the Compliance Department and Claims Policies and Procedures
- Develops materials, Trains claims examiners regarding the system and claim procedures and documents results
- Identifies and resolves various claims issues, documents, and reports results prior to every check run
- Resolves identified claims issues based on CCI edit report to comply with CMS guidelines
- Serves as a resource to Management, Customer Service, Utilization Management and other business units on claim issues
- Contributes to a fair and positive work environment by treating peers, superiors, subordinates, clients and vendors with professionalism and respect
- Participates in communication with Business Operations management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies and procedures
- Identifies and escalates issues related to instructional material that is inaccurate, unclear, or contains gaps. Provides recommendations for correction of this material.
- Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies
- Responsible for daily supervision of staff which included reviews, claims, correspondence, appeals, and enrollment situations that affect claims
- Prepares review sheets, quality review analysis, and corrective action plans of staff
- In collaboration with Claims Management, provides updates to staff on process changes, point of contact changes, etc.
- Collaborates with Director on workload, performance, or employee issues or concerns
- Hires, evaluates and develops staff
- Extracting relevant information from patient records
- Liaising with physicians and other parties to clarify information
- Reporting audits results of Coders assignments
- 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:
- American Academy of Professional Coders (AAPC) certification
- 2+ years in Medical Claims
- Experience working with Medicare / Medicaid / Managed Care claims
- Knowledge of healthcare regulations and guidelines including:
- CMS
- DMHC
- DHCS guidelines
- Proficiency with Excel
- Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding
- Ability to write routine reports and correspondence
- Ability to speak effectively before groups of customers or employees of the organization
- Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume
- Ability to apply concepts of basic algebra
- Ability to apply common sense understanding to carry out instructions furnished in written, oral, and diagram form
- Ability to deal with problems involving several concrete variables in standardized situations
- Proven detail oriented
- Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented
- Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues
- Successfully manage different styles of employees; Provide clear direction and effective coaching
- Technical Requirements:
- Knowledge and experience with Microsoft Word, and Outlook software
- Must be willing to learn applicable computer programs
- Behavioral Requirements:
- Demonstrate accountability for one’s own actions
- Ability to complete routine and priority tasks within departmental time frames
- Ability to convey care when answering phone calls and assisting customers
- Demonstrate the ability to effectively interact with both external and internal customers in difficult situations
- Demonstrate ability to make sound decisions
- Demonstrate accountability for one’s own actions
- Ability to complete routine and priority tasks within departmental time frames
- Ability to convey care when answering phone calls and assisting customers
- Ability to maintain confidentially when handling sensitive material
- Language Skills:
- Proficiency in speaking, reading, and writing English is required. Speaking Spanish, Vietnamese, Chinese and/or Tagalog is desirable but not required
Preferred Qualification:
- Intermediate skill levels in Microsoft Word, Excel, and Outlook
Physical Demands:
- The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
- While performing the duties of this position, the employee is regularly required to sit, possibly 90% of the workday, stand infrequently, use a computer keyboard frequently and intermittently throughout the day, and use hands to finger, handle, or feel objects, tools or controls. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to walk
- The employee must be able to infrequently lift and move up to 25 pounds. Specific vision abilities required by this position include close vision, color vision and the ability to adjust focus
- Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time
California Residents Only: The hourly range for California residents is $23.22 to $45.43 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.
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