Clinical Appeals Representative
About The Position
At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together Positions in this function are responsible for setting up the Appeals and Grievance cases for the Coordinators, Nurses and Doctors to review for a determination of denial. Position consists of reading and analyzing the member's correspondence and determining what the complaint is which could lead to several different issues. The Clinical Appeals Representative needs to be able to distinguish between Quality of Care, Appeal, Grievances, Expedited, Claims, Referral issues and determining exactly what the member is wanting in their letters. Position involves, calling to obtain the correct information from Member, Medical Groups, Providers, and other Departments. Position requires regulatory turnaround times. Accuracy is a very important part of this position. This position is full-time (40 hours/week), Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm PST. It may be necessary, given the business need, to work occasional overtime. Employees are required to work at least 3 days onsite (potentially more) and may be able to work some days from home. We offer 2-3 weeks of paid training. The hours during training will be 8:00 am - 5:00 pm PST, Monday - Friday. Training will be hybrid, some days in the office and some days at home. 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.
Requirements
- High School Diploma / GED
- Must be 18 years of age OR older
- 6+ months of Telephonic Customer Service experience
- Ability to use Microsoft Office, including Microsoft Word (create and edit correspondence), Microsoft Excel (ability to create, edit, and sort spreadsheets, basic analytical formulas (Vlookup)), and Microsoft Outlook (email and calendar management)
- Ability to type at the speed of 35+ WPM (words per minute)
- Must be available to work onsite at least three (3) days a week and may telecommute on other days if telecommuting requirements are met
- Availability to work overtime as needed during peak times and as mandated by the department
- Ability to work full-time (40 hours/week), Monday - Friday, in any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm PST
Nice To Haves
- Experience in Claims, Managed Care HMO, Doctor's office, and / OR Billing
- Experience in a healthcare environment
- Medical Terminology experience
Responsibilities
- Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting)
- Enter appeals and grievances details within the system and audit against provided documentation
- Determine where appeal or grievance should be reviewed / handled or route to other departments as appropriate
- Contact and work with other internal resources to obtain and clarify information
- Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes, and timeframes
Benefits
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
