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Claims Auditor - Managed Care - AppleCare Medical Management - Buena Park, CA
| Hours | Full-time, Part-time |
|---|---|
| Location | Buena Park, CA Buena Park, California |
About this job
This role is responsible for daily auditing of managed care claim payments. Will be responsible to monitor claims compliance by generating daily reports. This person is the liaison with internal and external clients to resolve provider/member claim issues. Responsible to train claims examiners and is a resource relating to claims guidelines.
Principal Duties and Responsibilities:
• To perform daily audits of claims payments as established in the Claims Department Policies and Procedures.
• To log all totals related to claims payment errors and examiner productivity for reporting purposes as established in the Claims Policies and Procedures.
• Trains claims examiners regarding the system and claim procedures.
• To review claims denial letters prior to issuing.
• Audit check runs and perform check payment process.
• Run daily claims report to monitor claims compliance.
• To manage the HMO claims deduct process.
• To track and generate request for claims overpayment.
• Resolve claims based on CCI edit report to comply with CMS guidelines.
• Serves as a resource to customer service, UM and other departments on claim issues.
• To contribute to a fair and positive work environment by treating peers, superiors, subordinates, clients and vendor with professionalism and respect.
• To perform other duties as directed.
Requirements
Requirements:
• 4+ years of managed care claims experience, with specific knowledge of CMS, DMHC, and DHS guidelines
• 2+ years of claims audit experience.
• GED/HS Diploma
Position Performance Criteria:
1. Initiative – ability to thoughtfully and independently resolve problems.
2. Organizational Skills – Ability to prioritize individual and departmental workloads.
3. Follow through.
4. Reporting Skills.
5. Technical and computer expertise.
6. Communication – Ability to identify and effectively communicate unresolved problems to Management in a timely manner.
7. Teamwork/Workplace Civility – Ability to work well with others and contribute to the overall positive work environment of both the Department and the Company.
8. Demonstrates high reliability through consistent punctuality and attendance.
Careers with AppleCare Medical Management/Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.