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Senior Claims Quality / Audit Representative - Cypress, CA

UnitedHealth Group

Cypress, CA
Job Code:
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Job Details

734605 Senior Claims Quality Audit Representative Cypress CA

Senior Claims Quality / Audit Representative - Cypress, CA (734605)

Position Description

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.

Responsible for the implementation and day to day performance of process activities related to claim research and resolution. These processes include the review of claims, contracts, and fee schedules to identify processing, procedural, systemic and billing errors. The incumbent actively communicates with cross-functional teams and other internal divisions to ensure that research and resolution opportunities are appropriately identified, pursued, and reported.
Primary Responsibilities:
  • Validate, research, and analyze claims payment problems and trends referred by Health Plan, bringing claim issues to resolution.
  • Coordinate designated claim processing adjustment activities and provide non-adjusted claims follow-up, ensuring closure with provider, member and / or health plan.
  • Ensure complete and appropriate documentation for all requested claim adjustments.
  • Facilitate and coordinate necessary adjustments and process improvements working with cross-functional teams including Customer / Provider Service, Claims, Network Management, Sales Administration, Care Coordination, Billing and Enrollment, and Group Entry.
  • Must work independently.
  • Must be comfortable communicating with Providers, Contracted entities and multiple internal departments via phone and email.
  • This position requires someone who is pro-active and willing to go the extra mile to resolve issues and propose solutions.
Required Qualifications:
  • High School Diploma or GED
  • 2+ years of Claims Processing or Customer Service experience answering claims inquires 
  • 2+ years of experience working in an HMO environment
  • Intermediate proficiency with a computer and Windows PC applications (this includes the ability to learn new and complex computer system applications)
  • 1+ years of experience in a medical background or medical billing
  • Ability to track daily inventory, sort, and retrieve data with Microsoft Excel
  • Ability to send, receive, and manage emails within Microsoft Outlook
Preferred Qualifications: 
  • Bachelor's Degree or Higher
  • Experience using NICE Claims Processing Screens
  • 1+ years of experience working with the Division of Financial Responsibility
Soft Skills:
  • Ability to make decisions and work independently
  • Solid written and verbal communication skills
  • Ability to manage multiple priorities
Physical Requirements and Work Environment:
  • Extended periods of sitting at a computer and use of hands/fingers across keyboard or mouse
Careers at UnitedHealthcare Medicare & Retirement. The Boomer generation is the fastest growing market segment in healthcare. And we are the largest business in the nation dedicated to serving their unique health and well-being needs. Up for the challenge of a lifetime? Join a team of the best and the brightest to find bold new ways to proactively improve the health and quality of life of these 9 million customers. You'll find a wealth of dynamic opportunities to grow and develop as we work together to heal and strengthen our Healthcare system. Ready? It's time to do your life’s best work.
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.
Keywords: Claims Processing, Customer Service, HMO environment, medical background, medical billing, Microsoft Excel, MS Outlook, NICE Claims Processing Screens, Senior Claims Quality/Audit Representative

Job Details

  • Contest Number734605
  • Job TitleSenior Claims Quality / Audit Representative - Cypress, CA
  • Job FamilyClaims
  • Business SegmentUHC Benefit Ops - MandR Ops

Job Location Information

  • Cypress, 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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