Create and execute test claims for development, UAT, QA, and configuration validation. * Perform ... Integrated Outpatient Code Editor (I/OCE) * Ability to collect, research, interpret, and document ...
Create and execute test claims for development, UAT, QA, and configuration validation. * Perform ... Integrated Outpatient Code Editor (I/OCE) * Ability to collect, research, interpret, and document ...
Optum Claims Editing information
What is the difference between Optum Claims Editing vs Medical Billing Specialist?
| Aspect | Optum Claims Editing | Medical Billing Specialist |
|---|---|---|
| Credentials | Certification in claims processing or related fields often preferred | Certification in medical billing or coding often preferred |
| Work Environment | Healthcare insurance companies, third-party administrators | Medical offices, hospitals, billing companies |
| Employer & Industry | Insurance providers, healthcare payers | Healthcare providers, billing services |
| Primary Focus | Reviewing and editing insurance claims for accuracy | Preparing 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 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 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.
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What cities in Nebraska are hiring for Optum Claims Editing jobs? Cities in Nebraska with the most Optum Claims Editing job openings:
Full-time
Medical, Life, Retirement, PTO
Posted 13 days ago
Signature Performance rating
6.6
Based on 8 frontline employees who took The Breakroom Quiz
309th of 485 rated business services
Job description
About You
The Payer Payment and Reimbursement Analyst will work with the team members in healthcare payment & reimbursement methodologies, laws and regulations under the mentorship and guidance of the Project Manager.
- Tell us about your experience with Payment and Reimbursement Methodologies.
- Are you a team player and a self-motivator?
- What is your experience with conducting business in a way that is credit to a company?
- We are counting on you to manage multiple projects using your problem-solving skills.
- We are looking for someone UNCOMMON. What is uncommon about you?
Are you highly committed? Are you team-oriented? Do you value professionalism, trust, honesty, and integrity? If so, we cannot wait to meet you.
About the Position
- Configure and maintain payment, pricing, and contract logic within healthcare reimbursement systems to ensure accurate claims adjudication.
- Analyze vendor bulletins, regulatory updates, and system changes to assess impact on internal processes, products, and data systems.
- Review and evaluate large healthcare data sets to identify trends, anomalies, and required system or process changes.
- Interpret Medicare, VA, CHAMPVA, and TRICARE policies, including rulings, transmittals, bulletins, manuals, and physician fee schedule data files.
- Collaborate directly with government agencies to clarify new or existing reimbursement and payment policies.
- Translate reimbursement policy updates and payment methodology changes into clear, actionable business requirements for software design and system configuration.
- Develop complex Excel models and formulas to validate, explain, and support payment methodologies.
- Identify claim data characteristics required for testing pricing logic and configuration accuracy.
- Partner with Developers, QA, Data, and Client Services teams to ensure requirements are implemented accurately and on schedule.
- Create and execute test claims for development, UAT, QA, and configuration validation.
- Perform configuration testing and troubleshoot pricing or payment discrepancies.
- Maintain deep knowledge of company products, data, and services, including commercial contracting and reimbursement features.
- Independently evaluate and resolve complex pricing and reimbursement issues while managing multiple priorities.
Core Competencies
- Strong analytical and critical-thinking skills
- High attention to detail and quality
- Ability to synthesize complex policy and data into practical solutions
- Effective collaboration and communication
- Self-directed with strong prioritization skills
Minimum Requirements
- 3-4 years of professional experience in healthcare provider payment and reimbursement.
- Working knowledge of healthcare billing, compliance, and payer reimbursement regulations.
- Experience with professional and institutional payment fee schedules, including but not limited to:
- Experience with Prospective Payment Systems (PPS), including:
- DRG, OPPS, Skilled Nursing, Home Health, Hospice, and ASC
- Experience with Prospective Payment Systems (PPS), including:
- Knowledge of:
- Critical Access, Sole Community
- Behavioral Health
- Inpatient Rehabilitation/Outpatient Rehabilitation
- Long Term Care Hospital
- Federally Qualified Health Center
- Physician Fee Schedule, DME/DEMPOS, Ambulance, AWP, Lab, ESRD, Hospice, Home Health, Anesthesia, ADA
- Integrated Outpatient Code Editor (I/OCE)
- Ability to collect, research, interpret, and document complex information into clear and concise business requirements.
- Strong interpersonal and cross-functional collaboration skills.
- Working knowledge of provider types, specialties, and their applicable reimbursement methodologies.
- Ability to communicate effectively with diverse internal and external stakeholders.
- SQL reporting experience preferred.
Preferred Requirements
- Proficiency in Microsoft Office applications (Teams, Word, Excel, PowerPoint, Visio, Access).
- Experience using web-based research tools and regulatory resources.
- Knowledge of claims adjudication and payment workflows.
- Experience configuring TriZetto Facets NetworX.
- Experience configuring Optum Rate Manager.
About Us
You are uncommon. We are, too. We are looking for people to help us in our mission of working hard at lowering healthcare administrative costs for federal government agencies, payers, and providers. At Signature, our mission is to improve the health of our clients' business and make the lives of the people we work with better. As we continue to experience exponential growth, we are looking for uncommon individuals to enhance our vision. We will continue to accomplish our mission by leading with our values of Passion, Courage, Integrity, and Respect in all interactions, making us a consistent annual Best Places to Work organization. We need uncommon leaders with uncommon qualities to shape our uncommon culture and achieve our uncommon mission.
About the Benefits
When you are a member of Signature Performance, you are a part of a solutions-based organization where the values of passion, integrity, courage, and respect are the driving forces behind all our decision-making. We trust you to do important work and bring the best version of yourself to work every day, so we want to help you achieve a work-life balance while consistently challenging yourself. Signature believes in fully developing each one of our Associates. Our performance-driven philosophy boasts competitive pay and additional position specific incentives, where world-class training and development, resources, and events drive our award-winning culture where everyone thrives.
- Health Insurance
- Fully Paid Life Insurance
- Fully Paid Short- & Long-Term Disability
- Paid Vacation
- Paid Sick Leave
- Paid Holidays
- Professional Development and Tuition Assistance Program
- 401(k) Program with Employer Match
- U.S. Citizenship or naturalized citizenship is required for this position.
- All work on all positions at Signature Performance must be completed in the continental United States, Alaska, or Hawaii.
What Signature Performance employees say
Pay
Benefits
Hours and flexibility
Workplace
Get the full story on Breakroom
About Signature Performance
Sourced by ZipRecruiter
Industry
Health care and social assistance
Company size
1,001 - 5,000 Employees
Headquarters location
Omaha, NE, US
Year founded
2004