Part Time Claims Examiner - National Remote

WellMed, part of the Optum family of businesses, is seeking a Claims Examiner to join our team in the U.S. Optum is a clinician - led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together. The 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. This position is part time (25 hours / week), Monday - Friday. Employees are required to have flexibility to work any of our shift schedules during our normal business hours of 6:00 AM - 9:00 AM CST. We offer weeks of paid training. The hours of the training will be based on your schedule or will be discussed on your first day of employment. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. 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
• Must be 18 years of age OR older
• 2+ years of experience in a metric - based environment (production, quality)
• 1+ years of experience with processing medical, dental, prescription, OR mental health claims
• 1+ years of experience with working in a fast - paced, high volume environment and processing 50+ claims per day
• Proficiency with Microsoft Office Suite (Microsoft Word, Microsoft Excel, Microsoft Outlook, etc.)
• Ability to navigate and learn new and complex computer system applications
• Ability to work any of our part time (25 hours / week) shift schedules during our normal business hours of 6:00 AM - 9:00 AM CST from Monday - Friday.

Preferred Qualifications:

• Reside within commutable distance to the office at 19500 W Interstate, San Antonio, TX, 78257

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

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