Appeals and Grievances Supervisor - San Juan, PR

UnitedHealth Group

4d•Onsite

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. Communicates with appropriate parties regarding appeals and grievance issues, implications and decisions. Analyzes and identifies trends for all appeals and grievances. May research and resolve written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians/providers.

Requirements

2+ years of leadership experience as a SME, Trainer, Team Lead or Supervisor
1+ years of experience with healthcare/medical terminology, or medical coding
1+ years of experience working in a production environment
Experience with Microsoft Tools: Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating/editing spreadsheets, filtering, navigating reports)
Ability to work 40 hours/week during standard business operating hours Monday - Sunday from 7am - 9pm AST
Ability to perform this role in an office setting or other company location
English & Spanish proficiency (verbal and written)

Nice To Haves

Experience working in appeals and grievance
Claims experience
Proven knowledge of claims processing and/or claims adjustments
Demonstrated working knowledge of FACETS, Linx, Qfiniti, Enligthen, ICUE, COSMOS and/or UNET platforms
Experience working with various payers, such as Medicare, Medicaid, and or Commercial insurance
Demonstrated exceptional relationship building skills, including effective communication, empathy, adaptability, and the ability to resolve conflicts and build trust

Responsibilities

Coordinates, supervises and is accountable for the daily activities of business support, technical or production team or unit
Provide hands-on support and guidance to ensure timely and accurate resolution of cases
Create and manage staff schedules, ensuring adequate coverage on weekends and during peak times. Monitor adherence to schedules and adjust as needed based on workload
Oversee the inventory of active and pending appeals .Ensure proper categorization, prioritization, and tracking of all cases
Act as the primary point of contact for client escalations that require immediate attention. Collaborate with stakeholders to resolve high-priority cases in a timely manner
Monitor aged and due cases, ensuring they are addressed promptly. Ensure the team actively works on reducing the backlog of older appeals
Set clear performance expectations for the team, conduct regular performance reviews, and provide coaching and feedback. Manage KPIs and ensure the team meets or exceeds goals
Prepare and present reports on case resolution times, aging inventory, and team performance. Identify trends and implement process improvements
Ensure all appeal and grievance resolutions comply with internal policies, regulatory guidelines, and client-specific requirements. Conduct regular quality audits
Sets priorities for the team to ensure task completion
Coordinates work activities with other supervisors
Develops plans to meet short-term objectives
Identifies and resolves operational problems using defined processes, expertise and judgment
Decisions are guided by policies, procedures and business plan
Other duties may apply