Eligibility Representative, Lead
Posted on: May 3, 2021
OVERVIEW OF POSITION:Responsible for the accurate maintenance of
computerized insurance information in the legacy system.-- Duties
include research, analysis and reconciliation of complex
eligibility issues.-- This position is required to effectively
communicate with all the departments within Optum, employer groups,
health plans, contracted vendors and members to establish members'
insurance coverage.ESSENTIAL FUNCTIONS:
- Consistently exhibits behavior and communication skills that
demonstrate--Optum's --commitment to superior customer service,
including quality, care and concern with each and every internal
and external customer.
- Researches, analyzes and reconciles the discrepancies between
health plan eligibility tape files and the legacy system according
to established department guidelines.-- Verifies that all
enrollments contain the correct group numbers, plan and effective
date as reported by the health plan.
- Obtains and input into the legacy system accurate
fee-for-service eligibility and benefits information for non-HMO
members including PPO, EPO, Medicare and POS product lines.
- Accurately inputs into the computer system manually all HMO
members that are not added by electronic tape process.
- Manually reconciles eligible HMO members in the legacy system
for health plans that are not processed by electronic tape.
- Researches and resolves discrepancies in the PCP assignment
between the health plan eligibility tape files and the legacy
system.-- Makes sure of accurate capitation payments to
- Reviews all waivers signed in the previous month and processes
accounts according to waiver guidelines.
- Interacts with members through the telephone to resolve
- Receives and researches telephone inquiries pertaining to
eligibility issues for all Optum sites, central departments (i.e.,
Utilization Review, Patient Services, Care Management, Business
Office, Claims), outside vendors, physicians, etc.
- Researches insurance coverage on new unverified members prior
to their scheduled appointments and communicates the outcome to the
site per established department guidelines.
- Follows through to resolution with health plan on unresolved
eligibility issues.-- Refers to Supervisor when additional
intervention is necessary.
- Adheres to the guidelines established by the Eligibility and
Care Management departments in assessing the appropriateness of
member requests to transfer to Optum.
- Researches claims that cannot be processed due to eligibility
issues and maintains 24-48 hour turnaround time to ensure claims
- Accurately links employer group to benefit plan in the IDX
system according to Eligibility department guidelines.
- Assists Supervisor/Lead in training new and existing staff
- Uses, protects, and discloses Optum patients' protected health
information (PHI) only in accordance with Health Insurance
Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned.EDUCATION:
- High school diploma, G.E.D. or equivalent.-- Includes special
certification required for specific jobs.EXPERIENCE:
- Over 1 year and up to and including 3 years of experience.
- 1 to 2 years working with HMO insurance verification.KNOWLEDGE,
- Computer literate.
- Proficient in all Microsoft applications.
- Keyboard skills equivalent to typing 40 wpm.
- Excellent customer service skills.
- Ability to follow verbal and written instructions.
- Strong verbal and written communication skills.-- Good command
of the English language, grammar and spelling.If you need to enter
a work site for any reason, you will be required to screen for
symptoms using the ProtectWell mobile app, Interactive Voice
Response (i.e., entering your symptoms via phone system) or a
similar UnitedHealth Group-approved symptom screener. Employees
must comply with any state and local masking orders. In addition,
when in a UnitedHealth Group building, employees are expected to
wear a mask in areas where physical distancing cannot be
attained.Careers with Optum. Here's the idea. We built an entire
organization around one giant objective; make health care work
better for everyone. Optum, part of the UnitedHealth Group family
of businesses, brings together some of the greatest minds and most
advanced ideas on where health care has to go in order to reach its
fullest potential. For you, that means working on high performance
teams against sophisticated challenges that matter. Here you'll
find incredible ideas in one incredible company and a singular
opportunity to do your life's best work. (SM)Diversity creates a
healthier atmosphere: Optum and its affiliated medical practices
are Equal Employment Opportunity/Affirmative Action employers and
all qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, age, national origin,
protected veteran status, disability status, sexual orientation,
gender identity or expression, marital status, genetic information,
or any other characteristic protected by law. Optum and its
affiliated medical practices is a drug-free workplace. Candidates
are required to pass a drug test before beginning employment.
Keywords: Optum, Torrance , Eligibility Representative, Lead, Other , Torrance, California
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