Job Information

Optum Sr. Audit Analyst, Claims in Seattle, Washington

Sr. Audit Analyst, Claims

Optum Care Network is now offering qualified candidates an opportunity to join our team as a Sr. Audit Analyst, Claims. Our company values innovative problem solvers promote personal and professional growth and provides a supportive working environment that affords all of its employees a healthy work/life balance.

The Sr. Audit Analyst, Claims is focused on working in a team environment that is focused on providing excellent customer (consumer/accountholder/client/provider) support related to CMS reporting requirements and interpretation, CMS protocols impacting claim operations, and external state audits.

Positions in this function are responsible for responding to client requests related to audits of claim payment accuracy and benefit set up accuracy on account-based products across various platforms in a timely and accurate manner. Responsibilities may include researching, troubleshooting and responding to client requests and may include triaging and responding to escalated issues as they relate to a customer’s claims payment & benefit set up accuracy, provider contract and rate inaccuracies and adherence to CMS & state protocols, and CMS & state reporting requests.

Optum Care Network creates the opportunity for independent private practitioners to thrive in Washington State. By providing clinical integration support and data driven quality improvement, we have created a high value delivery network, making it possible for our providers to remain focused squarely on their patients.

Status: Regular, Full-time, FLSA Exempt

Competitive Benefits

Primary responsibilities will include:

  • Uses pertinent data and facts to identify and solve a range of problems within area of expertise, on behalf of claim operations.

  • Investigates non-standard requests and problems, with some assistance from others.

  • Prioritizes and organizes own work to meet deadlines.

  • Provides explanations and information to others on topics within area of expertise.

  • Respond to customer/account audit support and requests within 24 hours.

  • Partner with other departments to resolve consumer/accountholder and client requests, timely and accurately.

  • Answer questions and resolve issues including escalated issues for consumer/accountholders and clients timely and accurately.

  • Update and maintain accurate issues/CAP logs as needed to track remediation efforts.

  • Create, utilize and follow P&P’s on a daily basis to complete work.

  • Respond to work direction from outside the team and follow through on requests in a timely manner.

  • Share information across team members to increase overall team knowledge and understanding of concepts, and to ensure consistent application.

  • Create and utilize standard templates to ensure consistency when responding to requests.

  • Confirm understanding of CMS & state protocols impacting claim operations to ensure ability to identify issues during the pre-audit sample prep including the ability to accurately identify claims and membership specific to the state/customer audit scope requirements subjected to the audit.

  • Maintain detailed knowledge of claim operations, P&P’s, mandates, exceptions, customer specific P&P’s pertinent to the specific Health Plan contracts.

  • Act as a technical resource to others in own function.

  • Anticipate customer needs and proactively identifies solutions.

  • Solves complex problems on own; proactively identifies new solutions to problems.

  • Plans, prioritizes, organizes and completes work to meet established objectives.

  • Demonstrates understanding of data elements within the assigned claims platforms.

  • Quality assurance of data universes – ability to identify data discrepancies and the solution to arrive at accurate data including the ability to accurately identify claims and membership specific to the state/customer audit scope requirements subjected to the audit.

  • Conducts current state analysis to gather current business, functional and non-functional requirements and constraints (i.e., "as-is" state).

  • Define desired future state requirements based on input from all applicable stakeholders.

  • Identify the business impact of system/application changes, using appropriate tools as needed.

  • Interacting with multiple states, partnerships with UHC and Optum Ops teams as well as the Ops Claims C&S BA's.

  • Support Internal Focus Audits requiring detailed end to end claim review ensuring the validity of internal claims processing.

Minimum Requirements:


  • High school education or equivalent experience, some college preferred.

  • Undergraduate degree or equivalent experience.


  • 2+ years of experience utilizing claims platforms such as Macess, NICE, GPS, COSMOS, Tickets, Xcelys and FACETS.

  • 2+ years of Healthcare experience.

  • Prior knowledge/experience with account-based products.

  • 1 -3 years of experience within a matrix organization, healthcare or insurance company.

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.