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LHI - Claims Resolution Specialist

Company: UnitedHealth Group
Location: Roswell
Posted on: May 14, 2020

Job Description:

At OPTUM, the mission is clear:

Help people live healthier lives and help make the health system work better for everyone
LHI is one of 4 businesses under OPTUMSERVE. OPTUMSERVE provides health care services and proven expertise to help federal government agencies modernize the U.S. health system and improve the health and well - being of Americans. By joining OPTUMSERVE you are part of the family of companies that make UNITEDHEALTH GROUP a leader across most major segments in the U.S. health care system.
LHI was founded in 1999 and acquired by OPTUM in 2011, LHI specializes in creating and managing health care programs through on - location services, patient - specific in - clinic appointments, tele - health assessments, or any combination based on customer need. LHI'S customizable solutions serve the diverse needs of commercial customers, as well as federal and state agencies, including the U.S. Departments of Defense, Veterans Affairs, and Health and Human Services.
There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Ready for a new path? Start doing YOUR LIFE'S BEST WORK.SM
The LHI - CLAIMS RESOLUTION SPECIALIST II will perform manual review of VACCN Dental Claims which require additional review to determine if payment or denial should be made according to defined VACCN Dental Claims business rules, industry standard claims processes, and/or prior claims adjudication experience.

PRIMARY RESPONSIBILITIES:

- Maintain an ongoing responsibility for assigned claims inquiries which entails assessment, education and coordination for members / health care providers throughout the United States via telephone while keeping a detailed record within the internal database. Establish and maintain positive relationships with members, providers and our claims contractors
- Manage inbound and outbound calls from providers and members to resolve claims issues
- Request and manage medical records to help determine potential program coverage and communicate results to the members
- Completion of system generated tasks, including documenting all results as required
- Prepare comprehensive reviews and summaries for claims appeals
- Point of contact for internal departments to answer questions relative to member claims
- Work with the leadership team to resolve issues as needed
- Able to handle emotionally charged phone calls and ability to deliver unfavorable claims outcomes
- Ability to communicate complex program criteria into easily understood summaries in both oral and written communication
- Validation of claim coverage in relation to program guidelines
- Compete activities and reporting as required by the fraud, waste and abuse plan

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.

Keywords: UnitedHealth Group, Roswell , LHI - Claims Resolution Specialist, Other , Roswell, New Mexico

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