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About Optum & UnitedHealth Group – Pioneering Health Equity at Scale
Welcome to a career that makes a difference. Optum, the technology‑driven arm of UnitedHealth Group, partners with providers, payers, and patients to transform the delivery of health care across the globe. With a mission to help people live healthier lives and a commitment to making the health system work better for everyone, we leverage cutting‑edge data analytics, advanced digital platforms, and a culture of inclusion to drive outcomes that matter.
As a member of our Institutional Claims team, you will be at the forefront of translating complex contractual agreements into clear, accurate payment decisions that directly impact patient care and provider sustainability. Working from the comfort of your own home, you’ll join a diverse community of professionals who value collaboration, continuous learning, and the power of technology to simplify the most challenging aspects of health‑care administration.
Position Overview – Why This Role Is a Game Changer
We are seeking a Remote Institutional Claims Examiner who brings a blend of analytical rigor, customer‑centric communication, and an unwavering eye for detail. This full‑time (40‑hour) role operates on an 8‑hour shift schedule within Pacific Standard Time (6:00 am – 2:30 pm PST), Monday through Friday, with occasional overtime or weekend coverage as business needs arise. The position offers a competitive hourly wage ranging from $19.47 – $38.08, comprehensive benefits, and a clear pathway for professional advancement.
Key Responsibilities – What Your Day Will Look Like
Claims Processing & Financial Responsibility
- Interpret HMO contract coverage language to determine accurate payment responsibilities for group plans, health plans, and contracted hospitals.
- Verify patient eligibility and co‑pay amounts before claim submission to ensure compliance with contractual terms.
- Adjudicate both UB‑04 and CMS‑1500 claim forms, applying the correct vendor contract rates and fee schedules.
- Utilize third‑party pricing software and Medicare Prospective Payment System (PPS) modules to validate claim amounts.
- Manually process paper‑based claims and electronic submissions, maintaining a meticulous audit trail for each transaction.
Customer Interaction & Issue Resolution
- Respond to inbound calls from patients, providers, and insurers, resolving claim discrepancies with professionalism and empathy.
- Draft clear, concise correspondence—including pending letters—for unclean claims and provide status updates to stakeholders.
- Escalate complex system or contract issues to the Assistant Supervisor, Manager, or Director of Claims as appropriate.
Compliance, Documentation & Quality Assurance
- Research authorizations, ensuring claims are processed in compliance with federal, state, and payer regulations.
- Maintain an organized, date‑ordered repository of daily claim transactions to support audit readiness.
- Apply regulatory guidelines to provider disputes, ensuring timely resolution and accurate payment.
- Achieve and sustain a minimum 95% quality rating on reviewed claims, meeting all production standards consistently.
Continuous Improvement & Special Projects
- Participate in special projects, system upgrades, and process improvement initiatives that enhance the efficiency of the claims workflow.
- Share best practices and contribute ideas to refine policies, tools, and training programs.
Essential Qualifications – What You Must Have
- High School Diploma or GED (additional education is a plus).
- At least 2 years of institutional claims adjudication experience within a Managed Care, IPA, or health‑plan environment.
- Strong command of medical terminology, ICD‑10, CPT, HCPCS, and related modifiers.
- Proficiency with Windows OS, Microsoft Office suite (Word, Excel, Outlook), and internet applications.
- Ability to work any of the designated 8‑hour shift schedules (6:00 am – 2:30 pm PST) and flexibility for occasional overtime or weekend coverage.
- Residence within the Pacific Standard Time Zone, with a dedicated, private home office and a reliable high‑speed internet connection that meets UnitedHealth Group standards.
Preferred Qualifications – What Sets You Apart
- Hands‑on experience with Epic Systems or other major EHR/claims management platforms.
- Prior exposure to DRG, OPPS APC, Ambulatory Surgery, ESRD, or RBRVS pricing models.
- Experience in handling both clean and unclean claims, with a track record of meeting prompt‑payment timelines.
Core Skills & Competencies – Success Factors
- Analytical Acumen: Ability to dissect complex claim data, identify discrepancies, and apply contractual rules accurately.
- Communication Excellence: Clear verbal, written, and interpersonal skills for effective interaction with patients, providers, and internal teams.
- Technology Savvy: Comfortable navigating multiple online tools, pricing modules, and telecommuting platforms securely.
- Time Management & Multitasking: Prioritize high‑volume workloads while maintaining precision and meeting deadlines.
- Team Orientation: Collaborative mindset that embraces feedback, shares knowledge, and contributes to a supportive virtual environment.
- Integrity & Confidentiality: Strict adherence to HIPAA and UnitedHealth Group privacy policies.
Career Growth & Learning Opportunities
Optum invests heavily in employee development. As an Institutional Claims Examiner, you will have access to:
- Two weeks of paid virtual onboarding and ongoing mentorship from seasoned claims supervisors.
- Continuous education resources, including certifications in coding, reimbursement, and health‑care analytics.
- Clear career ladders leading to senior examiner, claims lead, operations manager, or specialist roles in data analysis, compliance, or provider relations.
- Opportunities to participate in cross‑functional projects that broaden your exposure to emerging health‑tech initiatives.
Work Environment & Company Culture
Our remote workforce thrives on a culture of inclusion, respect, and purpose‑driven collaboration. Highlights include:
- Diversity & Inclusion: A global community that celebrates varied perspectives and backgrounds, fostering innovation and empathy.
- Flexibility: Work‑from‑home flexibility paired with structured schedules that support work‑life balance.
- Well‑Being Programs: Access to mental‑health resources, virtual fitness classes, and employee assistance programs.
- Recognition & Rewards: Incentive programs, peer‑to‑peer recognition, and performance‑based bonuses celebrate your contributions.
Compensation, Perks & Benefits
While exact figures vary by location and experience, you can expect a competitive hourly rate ($19.47 – $38.08) along with a robust benefits package that typically includes:
- Medical, dental, and vision coverage with multiple plan options.
- Prescription drug benefits and health‑care savings accounts.
- 401(k) retirement plan with company match and optional equity purchase program.
- Paid time off, holidays, and parental leave.
- Life insurance, disability coverage, and employee assistance programs.
- Professional development stipend for certifications, courses, or conferences.
The Impact You’ll Make – Your Role in Our Mission
Every claim you adjudicate is a building block in the broader effort to improve health outcomes for millions. By ensuring accurate payments, you enable hospitals to continue delivering high‑quality care, support patients in accessing essential services, and help UnitedHealth Group fulfill its promise of health equity.
How to Apply – Take the Next Step
Ready to join a team that values expertise, empathy, and innovation? Click the link below to submit your application and begin a career where your skills directly contribute to healthier communities.
Apply Now – Become an Institutional Claims Examiner at Optum
Closing Statement – Your Future Starts Here
At Optum, we believe that every employee has the power to shape the future of health care. If you are driven, detail‑oriented, and eager to grow within a supportive, forward‑thinking environment, we want to hear from you. Join us, and together we’ll continue to make health care work better—for you, for our members, and for the world.
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