Senior Appeals Representative

UnitedHealth Group•Tampa, FL

13h•Remote

About The Position

This position is National Remote. You’ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges. 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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. As SME you will be doing all end-to-end process. Work independently with support for leaders and members. Should be deadline driven and detail oriented, while holding accountability to all actions. Appeals would be assigned to them all day and pivot if needed. Work higher volume but requires less effort and less time spent working it. Employees in this position are responsible for responding, analyzing, and resolving written clinical or administrative appeal requests using the correct process, letter templates, appeal attachments and enclosures within the required timeframes for all level of care for all delegated accounts.

Requirements

High School Diploma / GED OR equivalent work experience
Must be 18 years of age OR older
2+ years of experience analyzing and solving appeals and grievances OR 2+ years of experience in a healthcare setting with knowledge of the medical claims and/or billing process
Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
Ability to work 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 7:00am – 6:00pm.
It may be necessary, given the business need, to work occasional overtime.
Ability to keep all company sensitive documents secure (if applicable)
Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.
Extensive work experience within own function.
Ability to multi-task, this includes the ability to understand multiple products and multiple levels of benefits within each product
Strong written communication skills including advanced skills in grammar and spelling
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Nice To Haves

Behavioral claims or appeals experience
Experience using Linx, ISET, ICUE, ACET, CSP Facets, ATS, Doc360, EnterpriseNow

Responsibilities

Research and resolve written appeals submitted by consumers and physicians/providers
Ensure appeals has been categorized correctly
Obtain additional documentation required for case review
Review case to determine if review by clinician is required
Render decision for non-clinical appeals using sound, fact-based decision making
Complete necessary documentation of final appeals or grievance determination using appropriate templates
Communicate appeal or grievance information to members or providers and internal/external parties within the required timeframes
Manage assigned inventory to ensure timely and accurate resolution of cases.
Act as a subject matter expert for your team on applicable regulatory guidelines and privacy policies.
Effectively draft correspondence that explains the claim resolution/outcome as well as next steps/actions for the member.