Claims Resolution Clerk-San Juan, PR

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Position Summary

The Claims Resolution Clerk is responsible for researching, analyzing, and resolving outstanding medical claims that are unpaid, aged, or denied. This role ensures timely reimbursement by communicating directly with commercial payers, reviewing claim statuses, and updating internal systems with accurate documentation.

• Investigate unpaid or aged claims to identify the cause of nonpayment and determine required follow-up actions
• Review and resolve denied claims, ensuring all necessary corrections or additional documentation are identified and submitted when appropriate
• Initiate outbound phone calls to commercial payers to verify claim receipt, check claim status, obtain processing updates, and request reprocessing when necessary
• Utilize medical provider portals to research claim details, confirm adjudication information, and track payer responses
• Verify claims receipt and processing timelines to ensure compliance with payer guidelines
• Gather and verify coordination of benefits (COB) information, including primary/secondary payer details, to ensure accurate billing and processing
• Update the internal UI/system with current claim statuses, TPL information, documentation from payer interactions, and next-step actions
• Collaborate with billing teams to resolve issues that impact claim payment
• Maintain accurate records of all communications and follow-up activities
• Meet departmental productivity and quality standards, ensuring timely resolution of outstanding claims

• Knowledge of medical billing, insurance claim processing, and payer requirements
• Solid attention to detail and problem-solving skills
• Ability to communicate professionally with payers and internal teams
• Experience using provider portals
• Understanding of coordination of benefits (COB) processes

• 1+ years of experience in a production environment
• Proficiency in MS Office with solid computer skills (e.g., experience working with multiple systems, keyboarding skills, Microsoft Word, and PowerPoint)
• Proficient verbal and written English skills
• Proven solid attention to detail and problem solving skills
• Demonstrated ability to communicate professionally with payers and internal teams
• Other duties may apply

• Knowledge of medical billing, insurance claim processing, and payer requirements
• Experience using provider portals
• Understanding of coordination of benefits (COB) processes