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Optum Claims Editing information

What is Optum Claims Editing?

Optum Claims Editing refers to the process and technology used by Optum, a health services company, to review and validate healthcare claims before they are submitted for payment. This process helps ensure claims are accurate, comply with payer rules and regulations, and identify potential errors or fraud. The claims editing system applies automated rules to check information such as coding accuracy, eligibility, and medical necessity. By catching issues early, Optum helps healthcare providers reduce claim denials and speed up reimbursement. Many organizations use Optum's solutions to streamline their revenue cycle and improve overall claims management.

What are the key skills and qualifications needed to thrive as an Optum Claims Editing specialist?

To thrive as an Optum Claims Editing Specialist, you need a solid understanding of medical billing, coding (such as ICD-10, CPT, and HCPCS), and health insurance processes, often supported by a degree in healthcare administration or a coding certification. Familiarity with claims editing systems like Optum CES, payer portals, and healthcare management software is essential. Attention to detail, analytical thinking, and strong communication skills help ensure accurate claim review and collaboration with providers. These skills are critical for minimizing claim denials, ensuring compliance, and optimizing healthcare reimbursements.

What are some common challenges faced in an Optum Claims Editing role, and how can I effectively address them?

In an Optum Claims Editing role, you may frequently encounter complex claim discrepancies, policy updates, and high volumes of claims requiring timely review. Staying current with insurance regulations and payer guidelines is key to minimizing errors and rework. Collaborating closely with team members, leveraging internal resources, and participating in ongoing training can help you stay effective and maintain accuracy. Proactively communicating with supervisors and cross-functional teams also ensures smoother resolution of challenging claims.

What is the difference between Optum Claims Editing vs Medical Billing Specialist?

AspectOptum Claims EditingMedical Billing Specialist
CredentialsCertification in claims processing or related fields often preferredCertification in medical billing or coding often preferred
Work EnvironmentHealthcare insurance companies, third-party administratorsMedical offices, hospitals, billing companies
Employer & IndustryInsurance providers, healthcare payersHealthcare providers, billing services
Primary FocusReviewing and editing insurance claims for accuracyPreparing and submitting medical bills to insurers

Optum Claims Editing specialists focus on reviewing and correcting insurance claims to ensure proper reimbursement, often working within insurance companies or third-party administrators. Medical Billing Specialists handle the entire billing process, including preparing and submitting claims to insurers. While both roles require knowledge of healthcare billing and insurance processes, Optum Claims Editing emphasizes claim accuracy and compliance, whereas Medical Billing Specialists focus on the end-to-end billing cycle.

What are popular job titles related to Optum Claims Editing jobs in California?

For Optum Claims Editing jobs in California, the most frequently searched job titles are:

What job categories do people searching Optum Claims Editing jobs in California look for?

The top searched job categories for Optum Claims Editing jobs in California are:

What cities in California are hiring for Optum Claims Editing jobs?

Cities in California with the most Optum Claims Editing job openings:

Optum Claims Editing jobs near you

Claims Manager, Medicare Advantage Plan (Flexible-Hybrid)

UCLA Health

Los Angeles, CA • On-site

$98K - $214K/yr

Full-time

Re-posted 15 days ago

UCLA Health rating

8.7

Company rating: 8.7 out of 10

Based on 137 frontline employees who took The Breakroom Quiz

6th of 898 rated healthcare providers

Job description

General Information
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Work Location: Los Angeles, CA, USA
Onsite or Remote
Flexible Hybrid
Work Schedule
Monday - Friday, 8:00am-5:00pm PST
Posted Date
06/24/2026
Salary Range: $98200 - 214600 Annually
Employment Type
2 - Staff: Career
Duration
Indefinite
Job #
28705
Primary Duties and Responsibilities
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Play a vital role on our Claims leadership team, you will manage a team of claim examiners, auditors, and support staff toward operational excellence. The Claims Manager of the Medicare Advantage Plan will:
  • Implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments.
  • Foster a positive, high-performing team culture focused on quality and exceptional customer service
  • Identify opportunities to enhance workflows, resolve complex claim issues, and develop practical standard operating procedures
  • Empower the team to navigate challenging scenarios with confidence and consistency

Salary Range: $98,200 - $214,600/annually
Note: This position is flexible-hybrid.
Job Qualifications
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We're seeking a self-motivated, service-driven leader with:
Required:
  • Bachelor's degree in business, health care or a related field and/or equivalent work experience
  • Five or more years of claims operations experience in a Medicare Advantage or related environment
  • Three or more years of managing personnel in a claims processing environment
  • In-depth knowledge of physician and facility billing practices, CPT coding initiatives, ICD-10 coding standards, and revenue/HCPCS coding
  • Understanding of provider network/IPA arrangements and reimbursement methodologies, etc.
  • Knowledge of standard electronic and paper claim formats
  • Familiarity with AMA and Centers for Medicare and Medicaid Services coding guidelines
  • Computer proficiency with Microsoft Office Suite and data visualization tools
  • Knowledge of HIPAA, DMHC, AB1455, and CMS reporting requirements
  • Background with claims editing software (e.g., Optum CES, Web Strat, McKesson, etc.)
  • Experience in implementing and managing Prospective Payment System vendor application (Optum PPS, MicroDyn, 3M, etc.). (preferred)
  • Expertise with one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXT
  • Excellent problem identification, resolution, and analytical abilities
  • Strong communication, interpersonal, and analytical skills
  • Ability to develop, implement, and evaluate methods/systems to improve efficiency
  • Ability to lead and facilitate cross-functional workgroups
  • Proficiency in achieving compliance with regulatory requirements
  • Ability to travel/attend off-site meetings and conferences

Preferred:
  • Certified Professional Biller (CPB)
  • Certified Revenue Cycle Representative (CRCR)

As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.
Current/former UC employees are subject to a personnel file review.

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About UCLA Health

Sourced by ZipRecruiter

UCLA Health, operating within the healthcare industry, is significantly recognized for its commitment to improving the health and wellbeing of people through the integration of patient care, research, and education. Located in Los Angeles, California, UCLA Health was founded and associated with the University of California, Los Angeles (UCLA) in 1955, entrenching its roots in quality healthcare service provision. Through a broad range of medical services, UCLA Health significantly stands as a cornerstone for comprehensive outpatient, inpatient, and emergency care services, specialized treatments, and wellness checks. Notable for pioneering an integrated, comprehensive medical approach, UCLA Health is consistently ranked among the top health systems in the US and world.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Los Angeles, CA, US

Year founded

1955

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