01Overview
```html About Optum & UnitedHealth Group Pioneering Health Equity at Scale Welcome to a career that makes a difference. Optum, the technologydriven arm of UnitedHealth Group, partners with providers, payers, and patients to transform the delivery of health care across the globe. With a mission to help people live healthier lives and a commitment to making the health system work better for everyone, we leverage cuttingedge data analytics, advanced digital platforms, and a culture of inclusion to drive outcomes that matter. As a member of our Institutional Claims team, you will be at the forefront of translating complex contractual agreements into clear, accurate payment decisions that directly impact patient care and provider sustainability. Working from the comfort of your own home, youll join a diverse community of professionals who value collaboration, continuous learning, and the power of technology to simplify the most challenging aspects of healthcare administration. Position Overview Why This Role Is a Game Changer We are seeking a Remote Institutional Claims Examiner who brings a blend of analytical rigor, customercentric communication, and an unwavering eye for detail. This fulltime (40hour) role operates on an 8hour shift schedule within Pacific Standard Time (6:00 am 2:30 pm PST), Monday through Friday, with occasional overtime or weekend coverage as business needs arise. The position offers a competitive hourly wage ranging from $19.47 $38.08, comprehensive benefits, and a clear pathway for professional advancement. Key Responsibilities What Your Day Will Look Like Claims Processing & Financial Responsibility Interpret HMO contract coverage language to determine accurate payment responsibilities for group plans, health plans, and contracted hospitals. Verify patient eligibility and copay amounts before claim submission to ensure compliance with contractual terms. Adjudicate both UB04 and CMS1500 claim forms, applying the correct vendor contract rates and fee schedules. Utilize thirdparty pricing software and Medicare Prospective Payment System (PPS) modules to validate claim amounts. Manually process paperbased claims and electronic submissions, maintaining a meticulous audit trail for each transaction. Customer Interaction & Issue Resolution Respond to inbound calls from patients, providers, and insurers, resolving claim discrepancies with professionalism and empathy. Draft clear, concise correspondenceincluding pending lettersfor unclean claims and provide status updates to stakeholders. Escalate complex system or contract issues to the Assistant Supervisor, Manager, or Director of Claims as appropriate. Compliance, Documentation & Quality Assurance Research authorizations, ensuring claims are processed in compliance with federal, state, and payer regulations. Maintain an organized, dateordered repository of daily claim transactions to support audit readiness. Apply regulatory guidelines to provider disputes, ensuring timely resolution and accurate payment. Achieve and sustain a minimum 95% quality rating on reviewed claims, meeting all production standards consistently. Continuous Improvement & Special Projects Participate in special projects, system upgrades, and process improvement initiatives that enhance the efficiency of the claims workflow. Share best practices and contribute ideas to refine policies, tools, and training programs. Essential Qualifications What You Must Have High School Diploma or GED (additional education is a plus). At least 2 years of institutional claims adjudication experience within a Managed Care, IPA, or healthplan environment. Strong command of medical terminology, ICD10, CPT, HCPCS, and related modifiers. Proficiency with Windows OS, Microsoft Office suite (Word, Excel, Outlook), and internet applications. Ability to work any of the designated 8hour shift schedules (6:00 am 2:30 pm PST) and flexibility for occasional overtime or weekend coverage. Residence within the Pacific Standard Time Zone, with a dedicated, private home office and a reliable highspeed internet connection that meets UnitedHealth Group standards. Preferred Qualifications What Sets You Apart Handson experience with Epic Systems or other major EHR/claims management platforms. Prior exposure to DRG, OPPS APC, Ambulatory Surgery, ESRD, or RBRVS pricing models. Experience in handling both clean and unclean claims, with a track record of meeting promptpayment timelines. Core Skills & Competencies Success Factors Analytical Acumen: Ability to dissect complex claim data, identify discrepancies, and apply contractual rules accurately. Communication Excellence: Clear verbal, written, and interpersonal skills for effective interaction with patients, providers, and internal teams. Technology Savvy: Comfortable navigating multiple online tools, pricing modules, and telecommuting platforms securely. Time Management & Multitasking: Prior .
