Denials and Refund Management Specialist - Concord, CA
Company: Optum
Location: Concord
Posted on: July 7, 2025
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Job Description:
Optum is a global organization that delivers care, aided by
technology to help millions of people live healthier lives. The
work you do with our team will directly improve health outcomes by
connecting people with the care, pharmacy benefits, data and
resources they need to feel their best. Here, you will find a
culture guided by inclusion, talented peers, comprehensive benefits
and career development opportunities. Come make an impact on the
communities we serve as you help us advance health optimization on
a global scale. Join us to start Caring. Connecting. Growing
together. The Denials and Refund Management Specialist will be
focused on refund requests – you will be reading, interpreting, and
analyzing commercial contracts. Once you are able to validate
whether or not the request is valid, you will submit the appeal to
contest the refund. Once the appeal is granted, you will request a
refund from the commercial payors due to the claim having been
declined instead of accepted. People who have a very extensive
background in interpreting and analyzing commercial contracts will
do well in this position. This position is full-time, Monday -
Friday. Employees are required to have flexibility to work any of
our 8-hour shift schedules during our normal business hours of 7am
– 3:30pm PST. It may be necessary, given the business need, to work
occasional overtime. Employees are required to work 1 day onsite
and 4 days from home. We offer 2 weeks of paid training. The hours
during training will be 8:00am - 4:30pm PST, Monday - Friday. If
you are within commutable distance to the office at 5003 Commercial
Circle, Concord, CA 94520, you will have the flexibility to work
from home and the office in this hybrid role* as you take on some
tough challenges. Primary Responsibilities: - Collect and resolve
denied payments from insurance companies by contacting assigned
payers - Execute the denial appeals process, which includes
receiving, assessing, documenting, tracking, responding to, and/or
resolving appeals with third-party payers in a timely manner -
Research and resolve payer rejected/denied claims and analyze
accounts for insurance payment accuracy/completeness and for payer
claim processing accuracy per contract. Work with clinical staff as
needed to follow-up and appeal denials - Maintain data on the types
of claims denied and root causes of denials, and collaborate with
team members to make recommendations for improvement and issue
resolution - Prepare, maintain, assist with, and submit reports as
required - Track and trend recovery efforts by utilizing various
departmental tools. Appropriately report on-going problems specific
to, health system departments, and/or contracts - Provide feedback
and process improvement ideas to management regarding facility,
Patient Access, Case Management, HIM, Billing and/or payer issues
identified when reviewing accounts for appeal - Draft professional
appeal letters in accordance with methodology in departmental
policy and procedure including using correct grammar and spelling -
Identify contract issues related to denials and communicate those
issues to Director of Revenue Integrity - Provide on-going feedback
to clinical staff about denial reasons, appeals and their outcomes,
and managed care contractual requirements - Transmit required
documentation to Government and third-party payers for the purpose
of resolving payments. - Ensure all payer contact is fully
documented in the appropriate software application - Ensure claims
are crossed over to secondary insurances, reporting any delay in
unbilled secondary claims to the unit supervisor - Consistently
meet the current productivity standards in addressing and resolving
denied accounts - Consistently meet the current quality standards
in taking appropriate actions to identify and track root causes,
successfully appeal denied accounts, and trend issues - Provide
individual contribution to the overall team effort of achieving the
department AR goal - Identify opportunities for system and process
improvement and submit to management - Demonstrate proficient use
of systems and execution of processes in all areas of
responsibilities - Demonstrate knowledge of John Muir Health System
HIPAA privacy standards and ensure compliance with system PHI
privacy practices - Follow the Health System’s general Policy and
Procedures, the Department’s Policy and Procedures, and the
Emergency Preparedness Procedures - Become cross-trained and fill
in for other staff as assigned - Follow department guidelines for
lunch, breaks, requesting time off, and shift assignments - Operate
office equipment and machinery and utilizes ergonomic workstations,
equipment, and supplies - Follow JCAHO and outside regulatory
agencies’ mandated rules and procedures - Utilize assigned menus
and pathways in the hospital mainframe system. Report software
application problems to the appropriate supervisor - Utilize
assigned menus and pathways in foreign software applications.
Report software application problems to the appropriate supervisor
- Utilize assigned computer hardware. Report hardware problems to
the appropriate supervisor - Participate in the testing for
assigned software applications, including verification of field
integrity - Perform other duties and responsibilities as assigned -
Maintain confidentiality in matters relating to patient/family -
Assure patient privacy and confidentiality as appropriate or
required - Ensure minors have a parent or guardian listed as
guarantor as appropriate - Maintain professional relationships and
convey relevant information to other members of the healthcare team
within the facility and any applicable referral agencies - Initiate
communication with peers about changes and procedures - Relay
information appropriately over telephone, email, and other
communication devices - Interact with internal customers including
HIM, Revenue Integrity, Patient Access, and the SBO in a
professional manner to achieve revenue cycle department AR goals
and objectives - Assist with special projects as assigned - Work
closely with other staff, co-workers, peers, and other members of
the healthcare team to ensure a positive and effective work
environment - Report to appropriate personnel regarding
assignments, projects, etc. - Initiate problem solving and conflict
resolution skills to foster effective work relationships with peers
- Report to work on time and as scheduled - Attend staff meetings,
in-services, and continuing education - Assist in the development
of indicators, thresholds, study methods, and data collection as
assigned - Respond to problems/opportunities to improve
care/customer service - Support involvement in system performance
improvement initiatives - Participate in and maintain competencies
required for the position and specific unit/area(s) of assignment
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. Required
Qualifications: - High School Diploma / GED - Must be 18 years of
age OR older - 2 years of experience with insurance follow-up
and/or payment variance review - 2 years EPIC experience - 2 years
hospital accounts billing follow up experience – not professional
billing - 2 years of experience analyzing commercial contracts
including interpreting commercial language - Ability to perform
mathematical calculations - Keyboard by touch - Advanced experience
and knowledge Microsoft Office including ability to open, create,
save, edit, and send Excel Spreadsheets, Word Documents, and
Outlook emails and calendar invites - Must be able to work in the
office at least one day a week - Ability to work full-time, Monday
- Friday. Employees are required to have flexibility to work any of
our 8-hour shift schedules during our normal business hours of 7am
– 3:30pm PST. It may be necessary, given the business need, to work
occasional overtime Telecommuting Requirements: - Reside within
commutable distance to the office at 5003 Commercial Circle,
Concord, CA 94520 - Ability to keep all company sensitive documents
secure (if applicable) - Required to have a dedicated work area
established that is separated from other living areas and provides
information privacy - Must live in a location that can receive a
UnitedHealth Group approved high-speed internet connection or
leverage an existing high-speed internet service Soft Skills: -
Strong organizational and project management skills - Strong
presentation skills - Negotiation skills - Leadership skills -
Detail-oriented, good organizational skills, and ability to be
self-directed - Ability to learn quickly and meet continuous
timelines - Strong time management skills, managing multiple
priorities and a heavy workload in a high-stress atmosphere -
Flexibility to perform other tasks as needed in an active work
environment with changing work needs - High-level problem solving,
analytical, and investigational skills - Excellent
internal/external customer service skills - Excellent communication
skills to include oral and written comprehension and expression -
Excellent communication skills when dealing with patients,
families, public, co-workers, and professional offices - Ability
and willingness to exhibit behaviors consistent with principles of
excellent service - Ability and willingness to demonstrate and
maintain competency as required for job title and the unit/area(s)
of assignment - Ability and willingness to exhibit behaviors
consistent with standards of performance improvement and
organizational values (e.g., efficiency & financial responsibility,
safety, partnership & service, teamwork, compassion, integrity, and
trust & respect) *All employees working remotely will be required
to adhere to UnitedHealth Group’s Telecommuter Policy Pay is based
on several factors including but not limited to local labor
markets, education, work experience, certifications, etc. In
addition to your salary, we offer benefits such as, a comprehensive
benefits package, incentive and recognition programs, equity stock
purchase and 401k contribution (all benefits are subject to
eligibility requirements). No matter where or when you begin a
career with us, you’ll find a far-reaching choice of benefits and
incentives. The hourly pay for this role will range from $20.00 -
$35.72 per hour based on full-time employment. We comply with all
minimum wage laws as applicable. At UnitedHealth Group, our mission
is to help people live healthier lives and make the health system
work better for everyone. We believe everyone–of every race,
gender, sexuality, age, location, and income–deserves the
opportunity to live their healthiest life. Today, however, there
are still far too many barriers to good health which are
disproportionately experienced by people of color, historically
marginalized groups, and those with lower incomes. We are committed
to mitigating our impact on the environment and enabling and
delivering equitable care that addresses health disparities and
improves health outcomes — an enterprise priority reflected in our
mission. UnitedHealth Group is an Equal Employment Opportunity
employer under applicable law and qualified applicants will receive
consideration for employment without regard to race, national
origin, religion, age, color, sex, sexual orientation, gender
identity, disability, or protected veteran status, or any other
characteristic protected by local, state, or federal laws, rules,
or regulations. UnitedHealth Group is a drug - free workplace.
Candidates are required to pass a drug test before beginning
employment. RPO RED
Keywords: Optum, Davis , Denials and Refund Management Specialist - Concord, CA, Healthcare , Concord, California