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Senior Claims Quality Audit Representative - Plano, TX

UnitedHealth Group

Plano, TX
Job Code:
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Job Details

740197 Senior Claims Quality Audit Representative Plano TX

Senior Claims Quality Audit Representative - Plano, TX (740197)

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.
The health care system is still evolving at a rapid pace. Technology is driving new advances in how patient care is delivered and how it's reimbursed. Now, UnitedHealth Group invites you to help us build a more accurate and precise approach to claims adjudication. In this role, you'll be responsible for the implementation and day to day performance of process activities related to claims research and resolution. This includes the review of claims, contracts, and fee schedules to identify processing, procedural, systemic and billing errors. Join us and build your career with an industry leader.
Primary Responsibilities:
  • Review, analyze, and audit examiners, supervisors, and claims to ensure compliance with company procedures and quality standards.
  • Analyze the source of quality problems and refer to the appropriate parties for follow-up or training; identify specific training needs and make recommendations to the Claims Trainer.
  • Maintain auditor production and quality standards.
  • Review overpayment files to reduce total claims overpayments.
  • Provide technical support to claims examiners and others as required.
  • Identify and investigate possible fraudulent or questionable claims practices.
  • Administer the Quality Review Program to determine the accurate and appropriate application of policy, including eligibility, investigation, and payment practices.
  • Evaluate examiner quality statistics and make recommendations to management for authority levels and focused audits as necessary.
  • Conduct special audits to track claims accumulating over large dollar limits.
  • Provide written and oral summaries of audit analyses as required.
  • Request, monitor, and analyze utilization, quality and vendor reports as required.
  • Make recommendations to management regarding changes to policies, procedures, and systems.
Secondary Responsibilities include, but are not limited, to the following:
    • Assist Claims Department as needed. 
    • Process claims as needed.
    • Assist with special claims projects as required.
    • Other special projects as required.
    Required Qualifications:
    • High School Diploma / GED or higher
    • 1+ years of experience processing medical claims
    • Working knowledge of medical terminology, CPT Codes and ICD-10 Codes
    • Ability to read and interpret health insurance policies and answer coverage questions
    Preferred Qualifications:
    • Experience with student medical claims
    • Experience with medical claims auditing or experience in a special investigations role
    Soft Skills:
    • Strong analytical and problem-solving abilities
    • Strong oral and written communication skills
    • Strong attention to detail
    • Effective time management skills, including organizational, planning and prioritization skills
    • Ability to perform activities requiring mental acuity, including but not limited to, some decision making, following procedures, use of visual and written sources of information and other activities requiring sustained concentration while sitting
    Careers at UnitedHealthcare Employer & Individual. We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of healthcare. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is 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, audit, quality, CPT codes, ICD-10, medical, student, insurance, policies, coverage

    Job Details

    • Contest Number740197
    • Job TitleSenior Claims Quality Audit Representative - Plano, TX
    • Job FamilyClaims
    • Business SegmentEmployer and Individual

    Job Location Information

    • Plano, TX
      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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