Professional Claims Examiner - Ontario, California

    • Ontario, CA

Position Description

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)

Primary Responsibilities:

  • Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims
  • Authorize appropriate payment or refer claims to leads or supervisors for further review
  • Analyze and identify trends and provides reports as necessary
  • Consistently meet established productivity, schedule adherence, and quality standards
  • Provide excellent customer service
  • Accurately process professional claims
  • Responsible for editing and adjusting of EDI claims
  • Analyze and adjudicate claims to ensure accurate payment
  • Interpret Fee for Service (FFS) and capitated provider contracts
  • Interfaces with other departments to obtain necessary information required for resolution of claims
  • Advise management of any claim issues or inappropriate and/or incorrect billing
  • Other duties assigned by management


You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • An education level of at least a high school diploma or GED
  • 1+ years' experience as a Medical Claims Examiner working on "Professional" claims
  • Solid experience with ICD9/10
  • Knowledge of DOFR and Provider contract interpretation
  • Proficient experience with Word and Excel


Preferred Qualifications:

  • Ability to multi-task, this includes ability to understand multiple products and multiple levels of benefits within each product
  • Prior Medicare, HMO experience
  • Working knowledge of Medical Terminology and CPT4
  • Excellent Data Entry skills


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).

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

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: Medical or Healthcare Claims examiner, Medicare, HMO, provider, ICD9, ICD10, DOFR, CPT Coding


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