Claims Examiner Representative - San Antonio, TX

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.(sm)

The Claims Examiner is responsible for accurate and prompt payment of claims, in addition to reporting of statistics/data. Examiners are responsible for adjudication of all claims, handling customer service calls as needed and recalculating claims as needed. Examiners will be expected to maintain production and quality standards.

Primary Responsibilities:

• Review claims for financial responsibility including determining coordination of benefits


• Review claims for duplicates, denials and referrals and ensures that claims information is matched to appropriate authorization


• Adjudicate claims appropriately per contract or standard processing guidelines which includes appropriate coding of CPT and ICD codes against charges that are being billed and entered


• Maintain prompt turnaround time on all claims and handle priority claims within 24 hours


• Handle all customer service audits and quality assurance errors/opportunities within 48 hours


• Coordinate with the Claims Manager and/or Claims Supervisor on workflow issues and the handling of batches in date order


• Document all claims production via the system BA screen (which tracks individual examiner production); online transactions to be tracked separately


• Must meet and maintain 95% quality expectations; these are identified via errors tracked on phone calls, overpayments, unsolicited checks, appeals, TDI complaints and errors on processing


• Create and generate any overpayment documentation (notes in system, written communications) on all overpayments created by an examiner or any overpayments identified by examiner


• Must meet and maintain 30 claims per hour on production


• Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction


• Performs all other related duties as assigned

Required Qualifications:

• High School Diploma or GED


• 1+ years of health care claims processing experience


• Medical terminology, 10-key and computer literacy skills


• Proficient with Medicare processing guidelines, working knowledge of medical contracts, RBRVS, facility and ambulatory payment methodologies


• Exceptional ability to organize, prioritize and communicate effectively


• Must have commonly-used knowledge of claims examination concepts, practices and rules, ICD and CPT coding and network contracts


• This position utilizes experience and judgment to plan, accomplish goals and effectively solve problems

Preferred Qualifications:

• 2+ years of relative experience

WellMed is a healthcare delivery system serving more than 90,000 patients, primarily Medicare eligible seniors, in Texas and Florida through primary care clinics, multi-specialty clinics, and contracted medical management services. Headquartered in San Antonio, Texas, WellMed is an industry leader in medical risk management, highly effective disease management and chronic care programs, healthcare delivery services and more.

Our focus and mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. We are innovators in preventative healthcare, striving to change the face of healthcare delivery for seniors. Our providers and support staff are selected for their dedication to the senior population and focus on preventative, proactive patient care.

Careers with 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, 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.

Job Keywords: Claims examiner, claims representative, billing, Utilization Management, San Antonio, TX