Clinical Appeals Representative
About the position 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 to start Caring. Connecting. Growing together. Positions in this function are responsible for setting up the Appeals and Grievance cases for the Coordinators, Nurses and Doctors to review for a determination of denial. Position consists of reading and analyzing the member's correspondence and determining what the complaint is which could lead to several different issues. The Clinical Appeals Representative needs to be able to distinguish between Quality of Care, Appeal, Grievances, Expedited, Claims, Referral issues and determining exactly what the member is wanting in their letters. Position involves, calling to obtain the correct information from Member, Medical Groups, Providers, and other Departments. Position requires regulatory turnaround times. Accuracy is a very important part of this position. 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 8:00 am - 5:00 pm PST. It may be necessary, given the business need, to work occasional overtime. Employees are required to work 3 days onsite and 2 days from home. Responsibilities • Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting) • Enter appeals and grievances details within the system and audit against provided documentation. • Determine where appeal or grievance should be reviewed / handled or route to other departments as appropriate • Contact and work with other internal resources to obtain and clarify information • Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes, and timeframes Requirements • High School Diploma / GED • Must be 18 years of age or older • 6+ months of Telephonic Customer Service experience • 35+ WPM typing skills • Ability to use Microsoft Office - Microsoft Word (create and edit correspondence), Microsoft Excel (ability to create, edit, and sort spreadsheets, basic analytical formulas (Vlookup), and Microsoft Outlook (email and calendar management) • Availability to work overtime as needed during peak times as mandated by the department. • Ability to work onsite at least 3 days a week at the Cypress, CA office and may telecommute when not in the office if meets Telecommuting requirements. • Ability to work 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 8:00 am - 5:00 pm PST. Nice-to-haves • Medical Terminology experience • Experience in Claims, Managed Care HMO, Doctor's office, and / or Billing Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution Apply tot his job