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Claims Quality / Audit Rep - Ontario, CA

UnitedHealth Group

Ontario, CA
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Job Details

751088 Claims Quality Audit Rep Ontario CA

Claims Quality / Audit Rep - Ontario, CA (751088)

Position Description

This position is responsible for reviewing, investigating and Auditing of Professional claims.


Primary Responsibilities:

  • Audit claims based on contractual arrangements with providers and non-contractual providers

  • Provide expertise claims support by reviewing, researching, auditing and explaining claims

  • Analyze and identify trends and provides feedback and reports to reduce errors and improve claims processes and performance

  • Responsible for all aspects of quality assurance

  • Performs complex and extensive research, analysis and logical conclusions of paper and electronic claims

  • Conducts necessary follow-up with internal. departments within set timeframes to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration

  • Acts as a department resource and gives support to Claims. Responds to Claims disputes in a professional manner

  • Identify, trend, and report provider issues to management for quality improvement.

  • Collaborates with other departments and management to implement and reinforce policy quality standards

Required Qualifications:

  • Minimum of 3+ years of experience as a Claims Examiner with previous Medicare and HMO experience

  • Professional claims processing experience

  • Ability to interpret Health plan division of financial responsibility matrix

  • Intermediate skill level with Excel


Preferred Qualifications:

  • High school diploma or a GED

  • Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding

  • Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals

  • Ability to communicate effectively in written or oral format

  • Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to concepts of basic algebra and geometry

  • Ability to commonsense understanding to carry out instructions furnished in written, oral, or diagram form

  • Ability to deal with problems involving several concrete variables in standardized situations

  • Ability to comprehend, interpret and provider contract language


Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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)


North American Medical Management, California, Inc. (NAMM California) partnered with OptumHealth in 2012. NAMM California and OptumHealth share a common goal of bringing patients, physicians, hospitals and payers closer together in the mission to increase the quality, efficiency and affordability of care. NAMM California is a part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system. NAMM California develops and manages provider networks, offering a full range of services to assist physicians and other providers in supporting patient care coordination and their managed care business operations. For over 18 years, NAMM California has been an innovator in health care with a track record for quality, financial stability, extraordinary services and integrated medical management programs. NAMM California is well positioned to continually invest in its infrastructure and systems for the benefit of its provider clients and to accommodate the impending changes that will come forth from healthcare reform.


The NAMM California provider clients represent a network of almost 600 primary care physicians and over 3,000 specialists and work with the premier hospitals in their respective markets.


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, appeals, CCI, Health plans, Correct Coding Initiative, HCFA-1500, UB-92, CPT Coding, Ontario, CA, California

Job Details

  • Contest Number751088
  • Job TitleClaims Quality / Audit Rep - Ontario, CA
  • Job FamilyClaims
  • Business SegmentOptumCare

Job Location Information

  • Ontario, CA
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusNon-exempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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