[Hiring] Claims Appeals & Adjustment Analyst @UnitedHealth Group

Role Description

Position in this function is responsible for the adjudication of complex medical/dental claims while maintaining minimum requirement for production and accuracy. Essential job functions include:

• Effectively working closely with Customer Service representatives to complete requests for claims adjustments through the CSR module.
• Reviewing and interpreting provider issues and member reimbursements for payment.
• Reviewing Claim Check guidelines and applying guidelines to claim payment.
• Performing departmental research necessary for monthly leakage reconciliation received from the health plans.
• Conducting pre/post analysis of high dollar payments and presenting summary to management.
• Reviewing returned checks and performing back out process of both provider return checks and refunds received; documenting member history as needed.
• Performing post provider audits, completing all provider adjustments, and completing provider invoices received.

Primary Responsibilities:

• Determine adjudication status based on audit review software.
• Perform claims adjustments initiated by providers, customer service requests, and health plans.
• Conduct pre/post analysis of high dollar payments, perform leakage reconciliation tasks.
• Initiate and report system/contract issues via TSU error log to TSU Team.
• Complete special projects, perform research of claims inquiries and claims correspondence.
• Identify incorrect payment trends via claims adjustment process and provider to trainer and supervisor.
• Complete back out function for returned checks and refunds received.
• Perform other duties as assigned.

Qualifications

• High School Diploma or equivalent.
• 5+ years of claims adjudication experience in a HMO, PPO, or TPA environment.
• Focus on Customer service and claims adjustments experience.
• Demonstrate solid working knowledge of payor contracts, provider/health plan reconciliation process, and EDI reconciliation process.
• Demonstrated understanding of medical terminology, CPT and ICD9 Coding and billing forms (HCFA/UB92).
• Ability to understand and/or interpret regulatory guidelines (i.e. SB418, HIPAA, etc.).
• Proven ability to interpret and apply contracts, fee schedules, and reimbursement methods.
• Proven self-directed and able to absorb new material quickly.

Requirements

• 3+ years experience as Claims Payment Analyst with KSC and demonstrated ability to process complex medical claims.
• 3 month course in business school.
• 10Key by touch 8,000 keystrokes.
• Typing (30 wpm).

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).
• Hourly pay for this role will range from $20 - $36 per hour based on full-time employment.