Appeals and Grievances Representative - San Juan, PR

UnitedHealth Group • PR

80d

About The Position

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. Positions in this function are responsible for providing expertise or general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances. This position will communicate with appropriate parties regarding appeals and grievance issues, implications and decisions. In addition, analyze and identifies trends for all appeals and grievances.

Requirements

• 1+ years of experience in a production environment.
• Experience in an office setting environment using the telephone and computer as the primary instruments to perform job duties.
• Experience with Microsoft Tools: Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports).
• Bilingual proficiency in English & Spanish (verbal and written).
• Ability to work 40 hours / week during standard business operating hours Monday - Saturday from 7am - 7pm AST (It may be necessary, given the business need, to work occasional overtime on weekends and holidays).

Nice To Haves

• Experience working or triaging appeals.
• Experience with ISET, ICUE and/or LINX.
• Behavioral Health Claims experience.
• Familiarity with Managed Behavioral Health Terminology.

Responsibilities

• Manage and resolve healthcare appeals work type in accordance with regulatory guidelines, client policies, and internal standards. Ensure timely resolution to meet required deadlines.
• Collect, review, and validate supporting documentation for appeals. Conduct thorough research to ensure accurate and fair case resolutions.
• Share and submit reports on case status, resolution times, and appeal to supervisors and other relevant stakeholders.
• Triage requests and determine the type of work received.
• Determine where specific appeals should be reviewed/handled, or routed to other departments.
• Classify and set up the case in the appeals system.
• Ensure accurate data entry based on research.
• Ensure all required documentation exists before proceeding with the appeal.
• Identify and obtain additional information needed to make an appropriate determination.
• Determine if appeal review is clinical or administrative.
• Research and make appropriate decisions on administrative cases.
• Coordinate with business partners to obtain decisions when appropriate.
• Review member benefit information, provider specific information/contracts, claims, applicable SOPs, nuance grid, delegation status, state specific and national policies and procedures in order to make accurate decision on the case.
• Ensure correct letter template is utilized and complete template with appropriate information and rationale.
• Select correct attachment and/or enclosure(s) and add to letter template.
• Send out completed and timely written notification letter within appeal requirements.
• May make verbal outreaches to providers/members.
• Prioritize work based on due date and run applicable work list reports to monitor workload.
• Plan, prioritize, organize, and complete work to meet established and required timeframes.
• Solve moderately complex problems on own.
• Employees are required to complete all work within the required timeframes and ensure all written and verbal communications are completed timely, accurately, and professionally.
• Supervision guidance may be needed for higher level tasks.
• Meet quality and productivity expectations.
• May coordinate work of other team members.
• Other duties may apply.

Benefits

• Comprehensive benefits and career development opportunities.

What This Job Offers

• Job Type: Full-time
• Number of Employees: 5,001-10,000 employees