Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes 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 make 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.

Under the supervision of the Medical Claims Review (MCR) Supervisor, this position is responsible for processing Utilization Management (UM) Inventory. The Sr. MCR Coordinator functions as a subject matter expert, and provides guidance to MCR Coordinators on more complex issues. Sr. MCR Coordinators are responsible for resolution of all claims within their capacity. Sr. MCR Coordinators are responsible for handling claim projects as needed. Sr. MCR Coordinators will be expected to maintain production and quality standards.

This position is full time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00 am – 4:00 pm. It may be necessary, given the business need, to work occasional overtime. Employees are required to work 3 days onsite and 2 days from home.

We offer 2-3 weeks of on-the-job training. The hours of the training will be aligned with your schedule.

If you are within commutable distance to the office at SAN ANTONIO-19500 W INTERSTATE, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.

Primary Responsibilities:

• Review claims for duplicates, denials and referrals and ensures that claims information is matched to appropriate authorization

• Prepares cases for Medical Directors, UM Nurses and Case Managers to conduct clinical review

• Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims

• Provide guidance and act as a resource to trainers and new hires on benefits, contract interpretations, exclusions, eligibility, policies, standard operating procedures, job aids and workflows to other MCR Coordinators in resolving complex issues

• Assist with escalated issues, and provide guidance as assigned and maintain prompt turnaround time on all claims and handle priority claims within 24 hours

• Meet department quality and accuracy standards

• Interface with other departments to obtain necessary information required for resolution of claims

• Take ownership of the total work process and provide constructive information to minimize problems and increase customer satisfaction

• Ensure documentation is completed in appropriate systems

• Prepare and monitor MCR inventory reports to ensure adherence to turnaround time requirements designated in contracts and/or relevant regulations

• Effectively communicate with all Supervisors and Directors

• Performs all other related duties as assigned

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:

• High School diploma/GED

• 18 years or older

• 2+ years of related managed care experience in Prior Authorization or Claim Review healthcare, and/or customer service

• 1+ years in the healthcare industry

• Knowledge of medical terminology, ICD-9 and CPT knowledge

• Proficiency with Microsoft Office applications

• Proficient with Medicare processing guidelines, working knowledge of medical contracts

• Ability to work any of our 8-hour shift schedules during our normal business hours of 7:00 am – 4:00 pm. It may be necessary, given the business need, to work occasional overtime. Employees are required to work 3 days onsite and 2 days from home.

Telecommuting Requirements:

• Reside within commutable distance to the office at San Antonio, TX

• Ability to keep all 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 UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

Soft Skills:

• Ability to organize, prioritize and communicate effectively.

• Ability to provide excellent customer service to a varied customer base

• Ability to navigate multiple systems

• Ability to work in a fast-paced environment

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe 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 experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

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 .

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