Remote Pacific Time Zone Claims Representative – Full‑Cycle Healthcare Claims Processing & Customer Experience Specialist (Work‑From‑Home)

About Optum – A Global Leader in Health Innovation

Optum, a division of UnitedHealth Group, is a technology‑forward health services organization that partners with millions of people worldwide to improve health outcomes and lower costs. By blending data, analytics, and a compassionate approach, Optum helps individuals navigate complex healthcare journeys, secure vital pharmacy benefits, and access the resources they need to thrive. Our culture is built on a foundation of diversity, inclusion, and continuous learning, empowering every team member to make a meaningful impact on the communities we serve.

Why This Role Is a Game‑Changer for Your Career

As a Remote Pacific Time Zone Claims Representative, you will be at the heart of our Manual Claims department, handling DMR (Direct Member Requests) and provider claims across all lines of business. This position offers a unique blend of analytical rigor, customer‑focused problem solving, and compliance stewardship. You’ll gain hands‑on experience with industry‑leading claims platforms such as RxCLAIM and WebView, while contributing directly to the timely delivery of care, the reduction of financial penalties, and the preservation of our STAR ratings.

Beyond the day‑to‑day responsibilities, you’ll join a high‑performing, fully remote team that values flexibility, accountability, and personal growth. Whether you are just starting your career or looking to deepen your expertise in healthcare claims, this role provides a clear pathway to advancement within Optum and the broader UnitedHealth Group family.

Key Responsibilities – What You’ll Do Every Day

• Claims Processing & Adjustment: Review, research, investigate, negotiate, and process provider and member claims with meticulous attention to accuracy and compliance.
• Trend Analysis & Reporting: Identify claim patterns, flag potential issues, and generate insightful reports that inform process improvements and strategic decision‑making.
• Productivity & Quality Assurance: Consistently meet or exceed established productivity targets, schedule adherence metrics, and quality standards while adhering to all regulatory requirements.
• Member & Provider Communication: Deliver clear, professional communication to members and providers, addressing inquiries, resolving disputes, and ensuring a positive experience throughout the claims lifecycle.
• Collaboration & Knowledge Sharing: Work closely with cross‑functional teams—including compliance, finance, and IT—to streamline workflows and share best practices.
• Continuous Learning: Participate in a structured 4‑8 week virtual training program, followed by ongoing coaching and development sessions to stay current on industry regulations and emerging technologies.

Essential Qualifications – What We Require

• Education: High School Diploma or GED (additional education or certifications are a plus).
• Experience: Minimum of three (3) years in an office, healthcare, or pharmacy environment, demonstrating familiarity with claims concepts or related processes.
• Technical Proficiency: Strong command of Windows‑based PC applications; ability to quickly learn complex claim processing systems such as RxCLAIM and WebView.
• Availability: Ability to work any of our 8‑hour shift schedules between 7:30 am – 4:00 pm Pacific Standard Time, Monday through Friday. Flexibility to cover occasional overtime or weekend work when business needs arise.
• Age Requirement: Must be 18 years of age or older.

Preferred Qualifications – What Will Set You Apart

• Claims Processing Experience: At least one (1) year of direct experience handling medical, dental, vision, or pharmacy claims.
• Medicare Knowledge: Familiarity with Medicare regulations, coding, and compliance guidelines.
• Certifications: Relevant industry certifications (e.g., Certified Professional Coder, Certified Claims Analyst) are advantageous.

Soft Skills & Core Competencies – The Personal Attributes We Value

• Critical Thinking: Ability to dissect complex claim scenarios, identify root causes, and devise effective resolutions.
• Independent & Team Collaboration: Thrive both as an autonomous contributor and as a collaborative team player.
• Adaptability: Comfortable juggling multiple tasks and shifting priorities in a fast‑paced environment.
• Accountability: Demonstrates high personal responsibility for meeting deadlines and quality standards.
• Professional Communication: Clear, courteous, and effective written and verbal communication with internal and external stakeholders.

Telecommuting Requirements – Setting You Up for Remote Success

• Reside within the Pacific Time Zone to align with business hours.
• Maintain a dedicated, private workspace separate from household activity, ensuring confidentiality of sensitive information.
• Secure a reliable high‑speed internet connection that meets UnitedHealth Group’s standards for speed and stability.
• Ability to safeguard all company documents and data in accordance with Optum’s Telecommuter Policy.

Physical & Work Environment – What to Expect

• Extended periods of seated work at a computer, with regular use of keyboard and mouse.
• Ergonomic considerations: recommended use of an adjustable chair, monitor at eye level, and occasional stretch breaks.
• All remote employees must adhere to UnitedHealth Group’s Telecommuter Policy, including data security protocols and performance monitoring.

Compensation & Benefits – What You’ll Receive

We offer a competitive hourly wage ranging from $16.00 to $28.85, determined by factors such as local labor market, experience, education, and certifications. In addition to base pay, you will be eligible for a comprehensive benefits package, which typically includes:

• Medical, dental, and vision insurance with multiple plan options.
• Prescription drug coverage.
• Retirement savings plans (401(k) with company match).
• Equity purchase program and incentive/recognition bonuses.
• Paid time off (vacation, sick leave, and holidays) and parental leave.
• Continuing education reimbursement and professional development resources.
• Employee assistance programs (EAP) for mental health and wellness.
• Access to wellness initiatives such as virtual fitness classes, mindfulness sessions, and health coaching.

All benefits are subject to eligibility criteria and may vary based on location and employment status.

Career Growth & Learning Opportunities – Your Path Forward

Optum invests heavily in the growth of its people. As a Claims Representative, you will have access to:

• Structured Onboarding: A 4‑8 week virtual training curriculum led by experienced subject matter experts.
• Mentorship Programs: Pairing with senior claims analysts and leaders to accelerate skill development.
• Cross‑Functional Rotations: Opportunities to explore related areas such as compliance, analytics, provider relations, or health information technology.
• Professional Certifications: Support for obtaining industry‑recognized credentials (e.g., CPC, CCIA).
• Leadership Development: Pathways to supervisory, managerial, or specialist roles within the claims ecosystem.
• Innovation Initiatives: Participation in projects that leverage artificial intelligence, data analytics, and process automation to transform claims handling.

Company Culture & Values – The Optum Way

Our culture is built on four pillars: Compassion, Innovation, Integrity, and Inclusion. We strive to:

• Foster a workplace where every voice is heard and respected, regardless of background or identity.
• Encourage curiosity and continuous improvement, empowering employees to experiment and share ideas.
• Uphold the highest ethical standards, ensuring compliance with healthcare regulations and protecting patient privacy.
• Celebrate achievements through recognition programs, peer‑to‑peer awards, and milestone celebrations.

As a drug‑free organization, all candidates must pass a pre‑employment drug screening.

Our Commitment to Diversity, Equity & Inclusion

UnitedHealth Group is an Equal Employment Opportunity and Affirmative Action employer. We evaluate each applicant without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability, veteran status, or any other characteristic protected by law. We believe that a diverse workforce fuels innovation and delivers better health outcomes for the populations we serve.

Application Process – How to Take the Next Step

If you are passionate about health equity, thrive in a remote environment, and meet the qualifications outlined above, we invite you to submit your application today. Our streamlined process includes:

1. Online Application Submission: Provide your resume, cover letter, and any relevant certifications.
2. Initial Screening: A brief phone interview to discuss your background and interest in the role.
3. Assessment & Interview: Skills‑based assessment followed by virtual interviews with the hiring manager and team members.
4. Offer & Onboarding: Successful candidates receive a competitive offer and begin the comprehensive virtual onboarding experience.

We strive for a transparent, respectful hiring journey and will keep you informed at every stage.

Join Us – Make an Impact from Home

At Optum, your work directly contributes to improving the health and well‑being of millions. By ensuring claims are processed accurately and efficiently, you help patients receive the care they need, providers receive timely reimbursement, and the health system operates more fairly and sustainably. If you’re ready to bring your expertise, curiosity, and dedication to a purpose‑driven organization, we encourage you to apply now.

Ready to Apply?

Take the first step toward a rewarding career with Optum. Click the link below to submit your application and begin your journey with a company that cares, connects, and grows together.

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