Manual Claims Analyst - Schaumburg, IL - Full-time / Part-time

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The Manual Claims Analyst is the frontline information resource for the claim processing professionals to answer questions and assist with escalations and Med D compliance issues. They must have the most in-depth knowledge of claims ensuring all claims are processed in keeping with performance guarantees, compliance for Med D and government regulations, and client and department specific policies and procedures. The Manual Claims Analyst administers the Quality Audit program for the team and department providing feedback, as required. The Manual Claims Analyst will assist in training of new hires, refresher training and will develop and maintain department procedure documents and policies and procedures. They will also assist in creating CAPs and help facilitate implementation of the CAP remediation in conjunction with department management. The Manual Claims Analyst will interact with internal departments with respect to maintaining knowledge of compliance and issue resolutions related to the claims adjudication process. They will also participate on department projects, as required.
 
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
 
Primary Responsibilities:


Develop and maintain documentation of department policies and procedures, client implementation documentation and compliance information as required

Understanding and awareness of Med D compliance, government regulations and policies and procedures for all new and legacy client business in order to ensure the team is compliant in their daily processes

Maintain ongoing relationship with Med D and Compliance departments to ensure the teams/department have the most relevant and updated knowledge of regulations and our audit programs are prepared to address compliance results

Participate on cross functional teams related to government and regulatory review

Knowledge of claims processing procedures including general claims processing, verifying member eligibility status and status of accounts and team workflow processes

Analyzes the nature and scope of issues related to claims adjudication and collaborates and coordinates with other departments for issue resolution/reconciliation

As necessary, inform supervisor/manager of any potential or actual system, procedure, plan set up questions and the need for system updates

Performing daily quality audit of processors and administrative staff’s work and tracking of all audited claims, in addition to 100% training audit. Preparing audit results for individual team members and supervisors

Analyzing reports including audit results to identify trends and opportunity areas within team and report to management team

Provides direction and guidance to team members who required additional support to meet department metrics

Train team members on new or existing processes

Recognizes and recommends areas of improvement to ensure customer and business needs are met

Assists with process improvement projects and metrics to ensure continuous adherence and improvement of established standards

Ensure quality control measurements on all claims functions as well as ensure the security of processing member claims and handling of member payments.

Provide timely feedback to team members on audit results focusing on coaching/training needs.

Prepare team operations metric, performance guarantee, audit universe and other ad hoc management reporting. Provides written, verbal and electronic reports as requested or required by management

Assists department management with preparation of presentation materials and status updates for executive management

Provide department supervisor/manager with accurate audit results for the team and team members, with trends noted for refresher training and coaching or policy and procedure update

Adheres to all individual employee performance standards including productivity, quality and attendance

Assist and participate on special team and department projects/cross functional work teams, as assigned

Participate in other department tasks/projects as required and necessary to meet business needs

Required Qualifications:


High School diploma or GED

Excellent analytical skills, solutions orientated

Able to work quickly and accurately under time constraints, working independently with strong team collaboration skills

Math, proofreading, computer and accounting aptitude

Strong attention to detail and analysis

Creative thinker with ability to identify best practices and streamlined processes that are customer focused. 

Able to respond in a calm, professional manner

Ability to plan and prioritize tasks within deadlines

Strong communication skills both written and verbal

Ability to multi-task to meet business needs

Knowledge of current Med D compliance, government regulations, policies and procedure related to pharmacy claim handling

Solid Microsoft Office Suite skills including Excel and PowerPoint

Knowledge of current Med D compliance guidance and regulations

Ability to handle sensitive material confidentially
Preferred Qualifications:


3+ years of pharmacy benefit processing experience
Assets:


RxCLAIM claim processing experience

Associates degree in Business Administration or other business level degree
 
Careers with OptumRx. We’re one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you’ll fill far more than prescriptions. As a member of one of our pharmacy teams, you’re empowered to be your best and do whatever it takes to help each customer. You’ll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There’s no better place to help people live healthier lives while doing 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.