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Healthcare Claims Auditor - La Palma, CA

UnitedHealth Group La Palma, CA Contractor
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The Healthcare Claims Auditor is responsible for reviewing all processed claims prior to paymentrelease, and respond to Health Maintenance Organization (HMO) Enrollees for Commercial,Medicare, and Medicaid Enrollees. Responsible for daily auditing of managedcare claim payments. Will be responsibleto monitor claims compliance with Medicare by auditing reports.  This person is the liaison with internal andexternal clients to resolve provider/member claim issues. Responsible to train claims examiners and isa resource relating to claims guidelines.

Primary Responsibilities
  • Toperform daily audits of claims payments as established in the Claims DepartmentPolicies and Procedures
  • Workwith Provider Disputes (PDR) and Appeals
  • Tolog all totals related to claims payment errors and examiner productivity forreporting purposes as established in the Claims Policies and Procedures
  • Trainsclaim examiners regarding the system and claim procedures
  • Auditpre check runs based on check run schedules
  • Runand resolve various claims reports prior to check run
  • Resolveclaims based on CCI edit report to comply with CMS guidelines
  • Servesas a resource to Management, Customer service, UM and other departments onclaim issues
  • Tocontribute to a fair and positive work environment by treating peers,superiors, subordinates, clients and vendor with professionalism and respect
  • Weare looking for candidates with the following strong attributes:
    • Initiative- ability to thoughtfully and independently resolve problems
    • OrganizationalSkills - ability to prioritize individual and departmental workloads
    • Alwaysfollows through on work
    • StrongReporting Skills
    • Technicaland computer expertise
    • Communication- ability to identify and effectively communicate unresolved problems toManagement in a timely manner
    • Teamwork/WorkplaceCivility - ability to work well with others and contribute to the overallpositive work environment of both the Department and the Company
    • Demonstrateshigh reliability through consistent punctuality and attendance
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Minimum2 years’ experience as a “Medical Claims Auditor” is required.

  • Experienceworking with Medicare / Medicaid / Managed Care claims

  • Experienceworking with Provider Disputes and Appeals

  • Knowledgeof healthcare regulations and guidelines including

    • CMS
    • DMHC
    • DHSguidelines

  • Intermediateproficiency with Excel

Preferred Qualifications:

  • AssociatesDegree (AA) or 2-3 years related experience and/or training; or equivalentcombination of education and experience.

  • Knowledgeof Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding.

Careers with Optum. Here's the idea. We built an entireorganization around one giant objective; make the health system work better foreveryone. So when it comes to how we use the world's large accumulation ofhealth-related information, or guide health and lifestyle choices or managepharmacy benefits for millions, our first goal is to leap beyond the status quoand uncover new ways to serve. Optum, part of the UnitedHealth Group family ofbusinesses, brings together some of the greatest minds and most advanced ideason where health care has to go in order to reach its fullest potential. Foryou, that means working on high performance teams against sophisticatedchallenges that matter. Optum, incredible ideas in one incredible company and asingular opportunity to do your life's best work.(sm)

AppleCare Medical Group was formed in Lynwood, California in1996 with the goal of making quality care available locally to the community.Today, AppleCare Medical Group is comprised of hundreds of board-certifiedprivate-practice, independent physicians. These physicians provide medicalexpertise and passion to improving the health of communities in the Southeastarea of Los Angeles and Northern Orange County.

AppleCare Medical Management Group was incorporated in 2003. Over thelast 17 years, the multispecialty medical group of independent practices hasexpanded into new communities, contracted with more hospitals and health plans,and added over 50 new doctors - but the mission has remained the same. Today,AppleCare Medical Management is comprised of hundreds of board-certifiedprivate-practice, independent physicians. Collectively, our physicians havebeen serving the Southeast area of Los Angeles and Northern Orange County fordecades, providing their medical expertise and passion to improving the healthof our communities.

Diversity creates ahealthier atmosphere: OptumCare is an Equal Employment Opportunity/AffirmativeAction employers and all qualified applicants will receive consideration foremployment without regard to race, color, religion, sex, age, national origin,protected veteran status, disability status, sexual orientation, genderidentity or expression, marital status, genetic information, or any othercharacteristic protected by law.


OptumCare is a drug-freeworkplace. Candidates are required to pass a drug test before beginningemployment.

 Job Keywords:Healthcare Claims Auditor, La Palma, CA, California


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