Provider Dispute and Appeal Specialist

UnitedHealth Group - Irvine, CA

The health care system is still evolving at a rapid pace. Technology is driving new advances in how patient care is delivered and how it's reimbursed. Now, UnitedHealth Group invites you to help us build a more accurate and precise approach to claims adjudication. In this role, you'll be responsible for the implementation and day to day performance of process activities related to claims research and resolution. This includes the review of claims, contracts, and fee schedules to identify processing, procedural, systemic and billing errors. Join us and build your career with an industry leader.

Primary Responsibilities:
Responsible for performing research and analysis to facilitate the resolution of provider / member claims issues based on regulatory requirements
Performs complex and extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers, members and health plans Conducts necessary follow-up with internal departments within set timeframes to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration
Acts as a department resource and gives support to Customer Service and researches Practice Connect issues for resolution. Responds to provider calls related to provider disputes and appeals for incoming provider / member disputes
Identify, trend, and report the Provider Dispute and Resolution process for Monarch Healthcare management and prepare reports for management summarizing observations and recommendations for quality improvement
Provides qualified data to the Business Operations Compliance & Regulatory Manager for incorporation into training programs and policies and procedures. Confers with management to assess training needs in response to identified trends
Collaborates with other departments and management to implement and reinforce policy quality standards

Required Qualifications:
Associates degree (A.A.) or related experience

2+ years related experience in the following areas:
Claims processing
Compliance and regulatory governing agencies (CMS, DMHC, DHS)
Provider dispute and resolution process (AB1455)
Provider appeals
Correct Coding Initiatives (CCI edits)
Contract language interpretation
Healthplan eligibility
Health Care Benefits

Preferred Qualifications:
Knowledge of HCFA-1500 and UB-92 claim forms
Intermediate skill levels in Microsoft Word, Excel, Access, and Outlook
Ability to operate general office equipment, i.e. fax, copier

What's the first thing that happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(sm)

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment