This position is responsible for reviewing all processed claims prior to payment release, and respond to all potential health plan capitation deduction report for Health Maintenance Organization (HMO) Enrollees for Medicare and HMO Enrollees. **Please note: This position would be in office in either our Irvine or Long Beach, CA office locations. If a candidate is selected for Long Beach, they would need to train in our Irvine office first. Primary Responsibilities:Performs routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration with ability to extract and audit exception audit reportsResearches claim processing problems and errors to determine their origin and appropriate resolution. Prepare reports and summarizes observations for management summarizing observations and recommendationsParticipates in communication with Business Operations management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies and proceduresIdentifies and escalates issues related to instructional material that is inaccurate, unclear or contains gaps. Provides recommendations for correction of this material. Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologiesPerforms special project audits and reviews as requested by other departments / regionsMaintains a minimum audit accuracy rateComplete other related duties as assignedRegular and consistent attendance
Required Qualifications: High school diploma or a GED3+ years of Medical Claims experienceExperience working with Medicare / Medicaid / HMOKnowledge of healthcare regulations and guidelines including CMS and MHC as pertains to AB1455. Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms, and CPT Coding Preferred Qualifications:Associates Degree (AA) or 2-3 years of related experience and/or training; or equivalent combination of education and experienceKnowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT CodingIntermediate skill levels in Microsoft Word, Excel, and OutlookAbility to write routine reports and correspondenceAbility to speak effectively before groups of customers or employees of the organizationAbility to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebraAbility to apply common sense understanding to carry out instructions furnished in written, oral, and diagram formAbility to deal with problems involving several concrete variables in standardized situationsDetail oriented What's the first thing that happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(sm) 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. Job Keywords: Claims examiner, Medicare, HMO, disputes, resolution, AB1455, provider, appeals, CCI, Health plans, Correct Coding Initiative, HCFA-1500, UB-92, CPT Coding, Irvine, CA, Long Beach, CA, California
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.