Clinical Appeals Reviewer

Employer: UnitedHealth Group

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 is a fast-paced, production driven environment and ability to multi- task is a must.

This position is full-time (40 hours/week) Monday – Friday. Employees must have flexibility to work either of our shifts between the hours of 9:00am 6:00pm or 10:00 am to 7:00 pm CST.

We provide 5-6 weeks of paid training. Hours during training are Monday through Friday 8 am to 5 pm CST (times could change based on trainer availability).

*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.
• Must be comfortable calling providers/members to review medical director determinations
• Verifying written letter determinations by reading and auditing for matching determination vs language
• Closing appeal cases using an automated “bot” or by manual process

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)
• Ability to work either of our shifts between the hours of 9:00am 6:00pm or 10:00 am to 7:00 pm CST

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 ISET

Telecommuting Requirements:

• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Ability to keep all company sensitive documents secure (if applicable)
• 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

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