Appeals Specialist - Remote in Central OR Eastern Time Zone

Company: UnitedHealth Group
Location: San Jose
Posted on: November 17, 2023

Job Description:

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.
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing your life's best work.SM
Appeals specialists perform various appeal management duties from when the appeal is open until it is resolved and closed. Healthcare providers appeal claims typically because they do not agree with the reimbursement paid to them. Utilizing available business rules and guidelines set by our clients, Appeals specialists apply discretion during discussions (including negotiations) with physicians, physician and hospital billers and finance staff, revenue cycle managers and others to determine the appropriate course of action as the specialist manages each appeal. The goal is to professionally resolve claim appeals in support of the pricing methodology used for each claim, while maintaining claim savings and minimizing additional claim payments for ClearHealth clients. Specialists will also perform other administrative duties as requested such as monitoring the group facsimile line and a general email and voicemail system that is dedicated to the appeals team.
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 7:00am - 6:00pm CST. It may be necessary, given the business need, to work occasional overtime.
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
Primary Responsibilities:

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• Ensure complaint 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 complaints 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 -
  
  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 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 years of work experience
    
  • 1+ years of experience analyzing and solving customer problems OR 1+ years of work experience in a related environment (i.e. office, administrative, clerical, customer service, etc.) using phones and computers as the primary job tools
    
  • Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
    
  • Must be 18 years of age or older
    
  • Ability to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 6:00pm CST. It may be necessary, given the business need, to work occasional overtime.
    
    Preferred Qualifications:
    
    • 
      
    • Experience with health care, medical, or pharmacy terminology
      
      Telecommuting Requirements:
      
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      • Reside within Central OR Eastern Time Zone
        
      • 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:
        
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        • Strong written communication skills including advanced skills in grammar and spelling -
          
          California, New Jersey, New York or Rhode Island Residents Only: The hourly range for California, New Jersey, New York or Rhode Island residents is $16.00 - $31.44 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
          At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for 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.
          -
          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.
          #RPO #YELLOW

Keywords: UnitedHealth Group, San Jose , Appeals Specialist - Remote in Central OR Eastern Time Zone, Other , San Jose, California