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Sr Consultant Claims Adjudication & Payment Integrity

UnitedHealth Group

San Antonio, TX
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Job Details

745071 Sr Consultant Claims Adjudication Payment Integrity

Sr Consultant Claims Adjudication & Payment Integrity (745071)

Position Description

The Sr. Consultant, Claims Adjudication & Payment Integrity position is responsible for the supervision of the claims / benefit configuration team performing the input of benefit plans, fee schedules, CPT codes, implementation and monitoring of ICES editing and configuration and administration of claim processes. They will determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.


Primary Responsibilities: 

  • Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
  • FWAE detection and identification of aberrant behavior for providers and facilities
  • Develops relevant training programs, policies and procedures, and resources that enable the claims and benefit load staff to process and perform job duties with accurate and timely information
  • Reviews and edits requirements, specifications, business processes and recommendations related to proposed solutions and write business rules to support benefit and claims functions
  • Perform data and root - cause analysis of business / system processes to ensure continuous process improvement across the enterprise
  • Works directly with management teams on quality results, trending analysis and needed process improvements
  • Assist with system testing and validation efforts
  • Ensure issues are identified, tracked, reported and resolved
  • Escalate issues to project team and management for support and / or guidance
  • Keeps abreast of current Medicare guidelines and Regulations and HMO compliance standards by reviewing all updates / bulletins and changes
  • Modifies the system specifications as changes in regulation occur


Required Qualifications:

  • Bachelor’s degree in Healthcare Administration or a related field
  • 8+ years of experience in medical benefits administration and medical claims processing environments including medical terminology, various payment methodologies relevant to Medicare Advantage
  • Coding certification through AAPC or AHIMA
  • 1+ years of Auditing experience

Preferred Qualifications:

  • 10+ years in a Medical Insurance environment
  • Pricing methodology knowledge
  • Experience working as business analyst with strong analytical and research skills
  • Experience working with process improvement teams and streamlining processes as required improving departmental efficiencies

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

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: Sr Consultant Claims Adjudication & Payment Integrity, San Antonio, TX, Texas

Job Details

  • Contest Number745071
  • Job TitleSr Consultant Claims Adjudication & Payment Integrity
  • Job FamilyHealthcare Economics
  • Business SegmentOptumCare

Job Location Information

  • San Antonio, TX
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelYes, 25 % of the Time
  • Telecommuter PositionNo
  • Overtime StatusExempt

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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