Claims Quality Auditor - Remote in CA

Optum CA is seeking a Claims Quality Auditor to join our team in California. Optum is a clinician-led care organization that is changing the way clinicians work and live.

The information below covers the role requirements, expected candidate experience, and accompanying qualifications.

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 Quality Auditor performs quality assurance functions as they pertain to Claims pre / post payment transactions through identifying, documenting, and communicating information.

The Claims Quality Auditor maintains and provides statistical reports to Claims Management as requested. Works cooperatively with the Claims Trainer and Claims Team Leaders to propose and implement solutions to provide the best outcomes for our Groups, Members, and Providers.

Supports activities related to internal / external audits to ensure timely dissemination of requested information / materials.

This position is full-time, Monday - Friday. Employees are required to work during our normal business hours of 8 : 00am - 4 : 30pm PST.

It may be necessary, given the business need, to work occasional overtime.

If you are located in California, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities :

• 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 Care Revenue and Network Management / Contracting and Finance and others) to ensure accurate information is in the system on a progressive basis

This is a challenging role with serious impact. You'll need strong analytical skills and the ability to effectively interact with other departments to obtain original claims processing details.

You'll also need to effectively draft correspondence that explains the claim resolution / outcome as well as next steps / actions for the member.

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
• Certified Coder
• Must be 18 years of age OR older
• 2+ years of experience working in a Healthcare Managed Care environment
• 2+ years of experience reviewing Claims Adjudication data
• Knowledge of CPT, RBRVS, ICD-10 coding, ASA, PDR, and regulatory requirements set forth by the DMHC, CMS and DHS agencies
• Proficiently skilled in the application and use of Windows Microsoft Word
• Proficiently skilled in the application and use of Windows Microsoft Excel
• Proficiently skilled in the application and use of Windows Microsoft Outlook
• Ability to work Monday - Friday, during our normal business hours of 8 : 00am - 4 : 30pm PST

Preferred Qualifications :

• Experience in Health Plan and Vendor contract interpretation
• Experience with HIPAA Regulation and California State Laws
• Quality assurance program experience
• Knowledge and experience of DRG, APC, & ASC claim pricing
• Knowledge of health plan requirements for claims processing
• Knowledge of eligibility, benefits, copays, deductibles, and claims examining theory

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
• All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

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

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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Remote working / work at home options are available for this role.