Optum Medical Claims Quality Auditor in SeaTac, Washington
Medical Claims Quality Auditor
Northwest Physicians Network, part of Optum, is now offering qualified candidates an opportunity to join our team as a Medical Claims Trainer. Our company values innovative problem solvers, promotes personal and professional growth and provides a supportive working environment that affords all its employees a healthy work/life balance.
The Claims Quality Auditor is responsible for all aspects of quality assurance within the Claims job family. Conducts audits and provides feedback to reduce errors and improve processes and performance. Generally audits are conducted of production staff equal to or lesser than the salary grade level so indicated.
Northwest Physicians Network, part of Optum, creates the opportunity for independent private practitioners to thrive in Washington State. By supporting clinical integration and data driven quality improvement, we have created a high value delivery network, making it possible for our providers to remain focused squarely on their patients.
Has basic knowledge of theories, practices and procedures related to claims/ claims quality
Performs routine or structured work.
Responds to routine or standard requests.
Uses existing procedures and facts to solve routine problems or conduct routine analyses.
Depends on others for instruction, guidance or direction.
Performs queries on relevant claims systems in order to obtain relevant information for audits
Validates claims data, member data, provider data against information from claims processing or business processing systems to ensure that data/decisions/payment and recovery/settlement information is accurate
Analyzes claims data against applicable policies and regulations to identify potential issues (e.g., member benefits, provider contracts, billing anomalies, payment accuracy, claims processing system issues, state mandates)
Reviews history of related claims to pull in and understand additional claims-related information
Maintains reporting infrastructure, as appropriate (e.g., SharePoint, Access databases)
Calculates dollar amount of financial claim errors/defects
Develops and delivers fact-based audit determinations in an objective, non-confrontational manner
Escalates issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Subject Matter Experts, Operations Team, Quality Team, business partners, team leads)
Ensures compliance with applicable audit and rebuttal timelines (e.g., calibration timelines, rebuttal timelines/form completion, workflows, turnaround time)
Achieves production quality goals/metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
Provides supporting documentation for audit findings
Manages audit inventory to ensure proper workload balance, coverage and closure
Identify/communicates escalated errors/defects and ensure proper resolution, as needed (e.g., calibrations, rebuttals, appeals)
- High School Education or Equivalent Experience
1-2 years prior experience in a transactions based operation
Prior knowledge/experience with account based products
1-2 years of experience within a matrix organization, healthcare or insurance company
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers 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. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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