Eligibility Representative, Lead

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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.


* Consistently exhibits behavior and communication skills that demonstrateOptums 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 providers.

* Reviews all waivers signed in the previous month and processes accounts according to waiver guidelines.

* Interacts with members through the telephone to resolve eligibility issues.

* 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 payment compliance.

* 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 members.

* 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.


* High school diploma, G.E.D. or equivalent. Includes special certification required for specific jobs.


* Over 1 year and up to and including 3 years of experience.

* 1 to 2 years working with HMO insurance verification.


* 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. Heres 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 youll find incredible ideas in one incredible company and a singular opportunity to do YOUR LIFES 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.
  • 1
  • Negotiable
  • None
  • None
  • Re-11206
  • Permanent
  • 1

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