Optum, a global healthcare organization, is dedicated to improving lives through technology-driven care. Join a culture of inclusion and collaboration where you can advance health optimization and make a tangible impact on communities worldwide. Our mission is to help people live healthier lives and create a more efficient health system for all.

This role is integral to investigating, resolving, and recovering various types of claims for health plans and commercial clients. It involves direct communication with members, providers, and other insurance companies to gather crucial coordination of benefits data. You will play a key part in pursuing subrogation claims and managing files, ensuring adherence to all state and federal compliance policies, reimbursement strategies, and contractual obligations.

Key responsibilities include preventing fraudulent or abusive claims using medical expertise, knowledge of coding systems (CPT/diagnosis), and adherence to client-specific guidelines. You will ensure compliance with all state and federal regulations and contractual agreements. This role may involve assisting the team with special projects and reporting, often requiring independent work without established procedures. You may also serve as a resource for colleagues and coordinate activities as needed. It is essential to comply with employment contract terms, company policies, and directives, including flexibility in work arrangements and locations, as the business environment evolves.

To be considered, candidates must have at least 12 months in their current role and meet other internal eligibility criteria. A Bachelor's degree in any field is required, with BHMS, BAMS, BUMS, BPT, MPT, B.Sc. Nursing, or BDS being preferred. For non-medical graduates, a minimum of 1 year of corporate experience in specialty coding (e.g., E&M, surgery) is necessary, along with relevant certifications such as CPC. Extensive experience in your functional area, proven attention to detail, quality focus, and strong analytical and comprehension skills are essential. Prior claims processing experience, health insurance knowledge, managed care experience, and familiarity with US healthcare coding and medical records are considered advantageous.