Claims Processing Professional

Posted 12 months ago

OPTIMED, A United Group Programs Brand, is an industry leader in Healthcare Benefits. We offer tailored healthcare products for our clients, focusing on the highest level of plan satisfaction and optimization. OPTIMED’s core strength is our people and their client centric approach to servicing members, providers and broker network.

Overall Position Description:

  • Under the supervision of our claims operations team the Claims Processing Professional is responsible for the initial examining, interpretation of coding and input of our members claims into our claims processing systems. The ideal candidate is self-motivated, detail oriented, and client centric.


  • Follow plan documented processes for entering claims into the claims processing application.
  • Follow OPTIMED/Plan documented processes for Initiating and processing claim adjustments in the claims processing application.
  • Audit claims processed by 3rd party outside vendor
  • Review claims to ensure proper information is on each claim to complete processing
  • Follow OPTIMED/Plan documented processes for resolving system edits in the data entry application.
  • Follow up with Provider claim submission discrepancies and missing documentation
  • Ensure timely and accurate payment or denial of claims and adjustments
  • Perform general clerical duties to ensure accurate disposition of claims that cannot be entered into the various processing systems
  • Perform other related duties as required by Management


Required Knowledge/Skills/Abilities

4-year college degree

  • Excellent oral and written communication skills
  • Must be a motivated, self-starter, with high initiative, and attention to detail.
    • Proven ability to work well in a fast-paced environment, interact in a team environment and foster positive attitudes
    • The ability to perform basic math calculations
    • The ability to read, understand, interpret and follow written direction
    • The ability to accurately perceive detailed information, including verbal and numerical material.
    • The ability to interpret coded information correctly

Preferred Knowledge/Skills/Abilities

4-year college degree

  • Some knowledge of health insurance industry.
    • Some experience with medical terminology, as well as billing and coding.
    • Knowledge of multiple systems, strong PC skills, typing skills of 40 wpm without errors. – Needs to demonstrate willingness to be cross-trained in other roles/duties.
    • Organizational, multi-tasking, and strong Interpersonal Skills
  • Ability to communicate with all levels of customers.
  • At least 1 (one) year of clerical business experience.
  • Experience working in a production and quality environment.

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