Clinical Appeals Representative - Remote

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. 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

In this role, you will constantly meet established productivity, schedule adherence, and quality standards while maintaining good attendance. You will also Receive Care Coordination notification cases for non-clinical assessment/intervention and provides appropriate triage; determine benefit coverage issues based on employer group contracts; set up/documents/triages cases / sends them to Triage RN to determine Urgency; ensures all potential member needs are identified and forwarded to the appropriate Care Coordinator for risk validation when applicable; assist with faxes and emails; and assign out Urgent / Escalated Cases to Appeals Team for Review.

The skillset that would be essential to perform this job would be:

• Multi-tasking
• Ability to work in a fast-paced, dynamic, rapidly changing environment
• Strong aptitude for working in a production driven environment.
• Must be a self-starter and able to work autonomously.

Although you will be working independently you are part of a team and Managers and/or Supervisors are available to assist with questions. You will be making very little outbound calls and receiving no inbound calls.

Each morning, this role will require to log in to systems such as ICUE, ETS, ECAA, ISET, Outlook, Teams, SharePoint. You will be required to take breaks and there will be a set lunch schedule.

This position is full-time (40 hours/week) Monday to Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 9:00am – 6:00pm CST. It may be necessary, given the business need, to work occasional overtime or weekends.

We offer 2 to 4 weeks of paid training. The hours during training will be 9:00am to 6:00pm CST, Monday to Friday.

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

Primary Responsibilities:

• Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis codes, Centers for Medicare/Medicaid Services guidelines along with referring to client specific guidelines and member policies
• Identify diagnoses and procedures basis the CPT and diagnostics codes and medical records supplied by provider
• Review medical record documentation to identify under coded and up coded services
• Research on provider data and member data to identify new or additional irregular billing patterns
• Interpret and analyze medical records as a mechanism for indexing medical information which is used for completion of statistics for hospital, regional and government planning and accurate hospital reimbursement
• Review of billing performances to ensure compliance with legal and procedural policies and to ensure optimal reimbursements while adhering to regulations prohibiting unbundling and other questionable practices
• Identify and abstract records consistently and accurately
• Assists with other ad hoc responsibilities deemed necessary by his/her supervisors
• Applies knowledge/skills to a range of simple to moderate activity
• Demonstrates great depth of knowledge/skills in own function
• Sometimes acts as a technical resource to others in own function
• Proactively identifies solutions to non-standard requests
• Solves moderately simple problems by himself
• May coordinate work of other team members

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)
• Computer proficiency in operating Microsoft Office Applications Excel (reading and producing reports) and Microsoft Outlook (managing calenda’s and mailboxes)
• Ability to work 1 holiday per year
• Ability to work 1 Sunday per Month for 2-3 hours

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

Preferred Qualifications:

• 1+ years of clinical/hospital experience
• Claims Processing experience in a BPO/HMO setting

Soft Skills:

• Ability to multitask and prioritize
• Ability to learn new and complex computer system applications
• Ability to communicate effectively
• Demonstrate a positive attitude and strong work ethic
• Offers to help fellow employees whenever possible
• Demonstrates a good rapport and works to establish cooperative working relationships with all members of the team
• Strong attention to detail

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 {apply below}

Learn how Teresa, a Senior Quality Analyst, works with military veterans and ensures they receive the best benefits and experience possible. {apply below}

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 10 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

Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $15.00 - $22.02. The salary range for Connecticut / Nevada residents is $15.00 - $24.13. 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

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.

Keywords: #RPO, #Yellow

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