Claims Resolution Clerk-San Juan, PR

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.

Position Summary

The Claims Resolution Clerk is responsible for researching, analyzing, and resolving outstanding medical claims that are unpaid, aged, or denied. This role ensures timely reimbursement by communicating directly with commercial payers, reviewing claim statuses, and updating internal systems with accurate documentation.

Primary Responsibilities:

Investigate unpaid or aged claims to identify the cause of nonpayment and determine required follow-up actions

Review and resolve denied claims, ensuring all necessary corrections or additional documentation are identified and submitted when appropriate

Initiate outbound phone calls to commercial payers to verify claim receipt, check claim status, obtain processing updates, and request reprocessing when necessary

Utilize medical provider portals to research claim details, confirm adjudication information, and track payer responses

Verify claims receipt and processing timelines to ensure compliance with payer guidelines

Gather and verify coordination of benefits (COB) information, including primary/secondary payer details, to ensure accurate billing and processing

Update the internal UI/system with current claim statuses, TPL information, documentation from payer interactions, and next-step actions

Collaborate with billing teams to resolve issues that impact claim payment

Maintain accurate records of all communications and follow-up activities

Meet departmental productivity and quality standards, ensuring timely resolution of outstanding claims

Skills & Qualifications:

Knowledge of medical billing, insurance claim processing, and payer requirements

Solid attention to detail and problem-solving skills

Ability to communicate professionally with payers and internal teams

Experience using provider portals

Understanding of coordination of benefits (COB) processes

***ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION***

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:

1+ years of experience in a production environment

Proficiency in MS Office with solid computer skills (e.g., experience working with multiple systems, keyboarding skills, Microsoft Word, and PowerPoint)

Proficient verbal and written English skills

Proven solid attention to detail and problem solving skills

Demonstrated ability to communicate professionally with payers and internal teams

Other duties may apply

Preferred Qualifications:

Knowledge of medical billing, insurance claim processing, and payer requirements

Experience using provider portals

Understanding of coordination of benefits (COB) processes

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.

Full-Time