Appeals Rep Sr

Combine two of the fastest-growing fields on the planet with culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that’s improving the lives of millions. Here, innovation isn’t about another gadget, it’s about making health care data available wherever and whenever people need it, safely and reliable. There’s no room for error. Join us and start doing your life’s best work. (sm)

This position is responsible for reviewing, investigating and completing the resolution of Provider Disputes in writing as set forth in laws pertaining to AB1455 for Commercial Health Maintenance Organization (HMO) Enrollees of Provider Disputes and Medicare Appeals for Medicare HMO Enrollees.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims
• Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers
• Adjust claims, as appropriate, including calculation of interest and penalties due when applicable
• Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Department’s ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
• Plan and organize workload to ensure efficient and compliance resolution of issues
• Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
• Responsible for requesting special check run requests to insure compliance
• Warning reports are monitored daily to insure compliance
• Provider education calls completed based on outcomes of PDR
• Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455
• Maintain minimum standards set for the department for quality and quantity of appeals received
• Update Provider Dispute Database with the outcome resolution of issues as appeals are completed
• Responsible for keeping Team Leads aware of potential problem issues for our education to all departments involved with claim issues. Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.
• Any other assigned duties and delegated by the Management

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 or a general education degree
• 3+ years of experience as a Claims Examiner with Medicare and HMO experience
• Working knowledge of medical terminology, ICD9, ICD 10, CPT4, HCPCs
• Working knowledge of UB04 and CMS 1500 Forms
• Ability to effectively interpret provider contract language and provisions
• Extensive HMO knowledge
• Familiar with AB1455, Knox Keene Act, Federal Register and Medicare Guidelines and Regulations
• Working knowledge of Revenue and HCPCS coding practices

Preferred Qualifications:

• Auditing and appeals experience
• Ability to communicate effectively
• Excellent grammatical and letter writing skills; in adherence to regulatory guidelines
• Excellent analytic skills
• flexible, self-starter, team player
• Able to work independently and solve moderately complex issues with limited supervision
• Ability to stringently manage, decipher and adhere to Regulatory timeframes for PDR and CMS Dispute processing

To protect the health and safety of our workforce, patients, and communities we serve, UnitedHealth Group and its affiliate companies now require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles require full COVID-19 vaccination as an essential job function. UnitedHealth Group adheres to all federal, state, and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidat es prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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Colorado, Connecticut or Nevada Residents Only: The hourly range for Colorado residents is $18.17 to $32.26. The hourly range for Connecticut / Nevada residents is $20.00 to $35.53. 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.

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

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.

Job Keywords: Provider, payments, claims, claims examiner, Medicare, HMO, dispute, resolution, analysis, AB1455, ICD-9, ICD-10, CPT4, HCPCs, UB04. CMS 1500, Knox Keene Act, Ontario, CA, California

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