Senior Claims Examiner - Remote in San Antonio, TX

If you are located reputed company commutable distance to 19500 W INTERSTATE I-10, San Antonio TX 78257 you will have the flexibility to telecommute* (work from home) as you take on some tough challenges. reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health reputed company by connecting... people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. WellMed is part of OptumCare, a division under the greater reputed company Group umbrella. We have a network of doctors, specialists and other medical professionals that specialize in providing the highest level of medical care for more than 1 reputed company older adults with over 16,000 doctors’ offices in Texas and Florida. We’re growing, and we are making a difference by helping our patients reputed company reputed company. With opportunities for physicians, clinical staff and non-patient-facing roles, you can reputed company a difference with us as you discover the meaning behindCaring. Connecting. Growing together. The Senior Claims Examiner is responsible for providing claims support to our teams in reviewing, analyzing, and researching reputed company health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. You'll need to be comfortable navigating across various computer systems to locate critical information. Attention to detail is critical to ensure accuracy which will ensure timely processing of the member's claims. This position is full-time (40 hours/week). Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6:00am – 6:00pm CST, Monday - Friday. It may be necessary, given the business need, to work occasional overtime or weekends. Our office is located at 19500 W INTERSTATE I-10, San Antonio TX 78257. We offer 20 weeks of on-the-job training. The hours during training will be an 8-hour shift between 8:00am – 4:30 PM CST, Monday - Friday. • reputed company Telecommuters will be required to adhere to reputed company’s Telecommuter Policy. Primary Responsibilities: • Review, process and identify medical claims based on standard operating procedures on CPS. • Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates). • Review and apply member benefit plans and provider reputed company, Pricing, CMS reputed company letter, SCA’s etc. to ensure proper benefits and contract language is applied to each claim. • Weekly/monthly goal of batches including meeting and maintaining a 95% quality standard and production standard of 90 claims per day. • Examine each claim for appropriate coding of CPT and ICD codes against charges that are billed and entered. • Manually adjust pended escalated claims to resolve reputed company issues reputed company to claim payments. • Adjudicate reputed company medical provider-initiated claims using analytical/problem solving skills. • Create and generate any overpayment documentation (notes in system, letter to typing) on reputed company overpayments created by the examiner or any overpayments identified by examiner. • Support implementation of updates to the reputed company procedures and participate in new system updates and training. • Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims errors/issues, using clear, simple language to ensure understanding. • Ensures reputed company claims reporting requirements are met; complete daily production reports and weekly pending reports. 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 reputed company development for other roles you may be interested in. Required Qualifications: • High School Diploma / GED • Must be 18 years of age OR older • 1 years of experience processing medical, dental, prescription or mental health claims • 1 years of experience working in a fast-paced, high volume environment processing 95 claims per day • 2 years of experience in metric-based environment (production, quality) • Proficiency with reputed company Office Suite (Outlook, Word, reputed company etc.) • Ability to navigate and learn new and reputed company computer system applications • Ability to work any of our 8-hour shift schedules during our normal business hours of 6:00am – 6:00pm CST, Monday - Friday. It may be necessary, given the business need, to work occasional overtime or weekends Telecommuting Requirements: • reputed company reputed company a commutable distance to 19500 W INTERSTATE I-10, San Antonio TX 78257 • Ability to reputed company reputed company company sensitive documents secure (if applicable) • Required to have a dedicated work area established that is separated from other living areas and provides information privacy. • Must live in a location that can receive a reputed company approved high-speed internet reputed company or reputed company an existing high-speed internet service. Soft Skills: • Proven exceptional ability to organize, prioritize and communicate effectively At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of reputed company, historically marginalized groups, and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company — an reputed company reputed company reflected in our mission. Diversity creates a healthier atmosphere: reputed company is an Equal Employment Opportunity / Affirmative Action employer, and reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. #RPO Apply Job!