Clinical Appeals Reviewer - Work from Home Details

Clinical Appeals Reviewer - Work from Home

UnitedHealth Group - Dallas, TX

Employment Type : Full-Time

If you are located within Central or Eastern Time Zone, you will have the flexibility to telecommute* (work from home) as you take on some tough challenges.

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work . SM

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work. SM

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.

This position is full-time (40 hours/week) Monday - Friday. Employees are required to work our normal business hours of 8:00am – 5:00pm local time. Overtime may be requested per business need. Training is virtual and 8 weeks long from 8:00 AM – 5:00 PM CDT.

What are the reasons to consider working for UnitedHealth Group ? Put it all together - performance based pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success.

Some of our offerings includes:

  • 18 days of Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
  • Medical Plan options along with participation in a Health Spending Account or a Health Saving account
  • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
  • 401(k) Savings Plan, Employee Stock Purchase Plan
  • Education Reimbursement - up to $5,250 per calendar year for job-related coursework
  • Employee Discounts
  • Employee Assistance Program
  • Employee Referral Bonus Program
  • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
  • More information can be downloaded at: http://uhg.hr/uhgbenefits

When it comes to talent and remarkable individual achievements, we are 180,000+ strong. But why do they choose a career path with us? As a Fortune 10 leader, we’ve created an environment that brings out their best in all the ways that make them special. We’ll provide you with a mission and a culture that make the most of it.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

  • Analyze / research / understand how a claim was processed and why it was denied
  • Obtain relevant medical records to submit appeals or grievance for additional review, as needed
  • Review medical records for missing documentation and request missing documentation
  • Set up case with all relevant documents, medical records, and benefit documents
  • Responsible for managing appeal case load routed from the department Medical Management queue in the Escalation Tracking System (ETS) to the Coordinator’s personal work queue in ETS
  • Ability to identify the correct type of appeal and re-route correspondence determined not appropriate for processing within the department
  • Appropriately and completely entering the appeal triage template into ETS
  • Ensure that the appeal cases are appropriately and timely assigned to the Nurse Reviewers in ICUE and ETS
  • Upload all appropriate case documentation into the Enterprise Clinical Archive Application (ECAA)
  • Develop and maintain a position of first contact with the Resolving Analysts within Benefit Operations and the Admin/Nurse Reviewers to ensure that appeal cases are completed within the require compliance timelines
  • Ability to analyze documentation workflow within the department and to make recommendations to department supervisors/managers for improvement

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 higher)
  • 1+ years of customer service experience
  • Proficiency in Microsoft Office suite: Microsoft Word (create and edit correspondence), Microsoft Excel (create, edit, and sort spreadsheets), and Microsoft Outlook (email and calendar management)

Preferred Qualifications:

  • 1+ years of healthcare insurance experience
  • Previous appeals / grievances experience
  • Previous claims experience
  • Familiarity with medical terminology
  • Experience with ETS, UNET, iCUE/HSR and/or ISET

Telecommuting Requirements:

  • Resides within Central or Eastern Time Zones
  • 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:

  • Strong time management skills

UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

Military & Veterans find your next mission: We know your background and experience is different and we like that. UnitedHealth Group values the skills, experience and dedication that serving in the military demands. In fact, many of the values defined in the service mirror what the UnitedHealth Group culture holds true: Integrity, Compassion, Relationships, Innovation and Performance. Whether you are looking to transition from active duty to a civilian career, or are an experienced veteran or spouse, we want to help guide your career journey. Learn more at https://uhg.hr/transitioning-military

Learn how Teresa, a Senior Quality Analyst, works with military veterans and ensures they receive the best benefits and experience possible. https://uhg.hr/vet

Careers with UnitedHealthcare . Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near - obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, Military families, and Veterans wherever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life’s best work. SM

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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

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Posted on : 2 years ago
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