Senior Appeals Representative

Senior Appeals Representative

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 a Senior Appeals Representative, 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.

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 7:00 am - 6:00 pm local time. It may be necessary, given the business need, to work occasional overtime or weekends.

This will be paid on the job training and the hours during training will be 8:00 am to 5:00 pm, Monday - Friday.

Primary 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
• Must have exceptional multi-tasking skills with the ability to prioritize tasks

This is a challenging role with serious impact. You'll need strong analytical skills and the ability to effectively interact with other departments to obtain original claims processing details. You'll act as a subject matter expert for your team on applicable regulatory guidelines and privacy policies. You'll also need to effectively draft correspondence that explains the claim resolution/outcome as well as next steps/actions for the member.

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.

Required Qualifications:

• High School Diploma / GED OR equivalent work experience
• Must be 18 years of age OR older
• 2+ years of experience with analyzing and solving appeals and grievances OR 2+ years of experience in a healthcare setting with knowledge of claims and/OR claims adjustments
• Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
• Ability to work any of our full time (40 hours/week), 8-hour shift schedules during our normal business hours of 7:00 AM - 6:00 PM local time from Monday - Friday. It may be necessary, given the business to work occasional overtime or weekends.

Preferred Qualifications:

• Behavioral claims OR appeals experience
• Previous experience with using Linx, ISET, ICUE, ACET, CSP Facets, ATS, Doc360, EnterpriseNow

Telecommuting Requirements:

• 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.

Soft Skills:

• Extensive work experience within own function
• Work is frequently completed without established procedures
• Works independently
• May act as a resource for others
• May coordinate others' activities. 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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. 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. The hourly pay for this role will range from $20 - $36 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.