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Sr. Claims Examiner (Healthcare) - Ontario, CA

UnitedHealth Group

Ontario, CA
Job Code:
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Job Details

754128 Medical Claims Examiner La Palma CA

Sr. Claims Examiner (Healthcare) - Ontario, CA (754128)

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)
To process the medical claims of the company’s IPA clients pursuant to designated production quotas for accuracy and productivity benchmarks.

Primary Responsibilities:
  • Batch and prioritize claims processing utilizing the Company’s in-house claims processing system
  • Verify patient’s accounts for eligibility and benefits
  • Process complex claims that have been accepted for payment
  • Request and follow-up on additional information as needed for incomplete claims
  • Complete all steps above within designated timeframes (production quotas) and notify management if claims cannot be processed within the designated time frame
  • Assemble denial letter background information and generate denial letters
  • Read, interpret and summarize medical contracts/division of responsibility
  • Identify claims that are not our financial risk and forward to appropriate entity for payment
  • Review claims that are pending and follows through for payment in a timely manner
  • Treat peers, superiors, subordinates clients and vendors with fairness, courtesy and professionalism and contribute to the overall positive work environment of the department
  • Covering for Supervisor at times
  • Complete other production projects as assigned

Required Qualifications:

  • An education level of at least a high school diploma
  • Requires 3+ solid years’ continuous experience working as a Healthcare/Medical “Claims Examiner”.

  • Contract and DOFR interpretation experience. 

  • Strong proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications

Preferred Qualifications:

  • Experience working on claims in a managed care setting
  • Team Lead experience

  • Ability to multi-task, this includes ability to understand multiple products and multiple levels of benefits within each product

  • Demonstrates excellent interpersonal skills as discerned through observation and team project successes

  • Accurately interprets and applies departmental policies and procedures using sound judgment as is related to claims processing

  • Communicates clearly, professionally and respectfully to peers, superiors, subordinates and clients

  • Meets production quota for both input levels and accuracy on a weekly basis as set forth by the department standards

  • Efficiently organizes and prioritizes workflow

  • Provides constructive feedback on work projects assigned

  • Consistently produces accurate and timely work product as it relates to departmental goals

  • Demonstrates high reliability through consistent punctuality and attendance

  • Demonstrates overall professionalism in attitude, demeanor and personal appearance

Making claims a positive experience for our members can drive your sense of impact and purpose. Join us as we improve the lives of millions. Learn more about how you can start doing 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 managers 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: career growth, benefits, work environment, La Palma, CA, California

Job Details

  • Contest Number754128
  • Job TitleSr. Claims Examiner (Healthcare) - 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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