UNITEDHEALTH GROUP: Clinical Appeals Representative - National Remote

Employer: UnitedHealth Group

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

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.

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, Monday- 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 regardless of what time zone you are in. 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:
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
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.
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)
Appeals experience in a healthcare setting
Ability to work 2 holidays per year and 1 Sunday per month
Computer proficiency in operating Microsoft Office Applications including Microsoft Word (reading, reviewing, and updating documents), Microsoft Excel (reading and sorting data), and Microsoft Outlook (managing calendars and mailboxes), and Microsoft PowerPoint (reading slides)
Ability to work full-time, Monday- 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 regardless of what time zone you are in. It may be necessary, given the business need, to work occasional overtime.
Preferred Qualifications:
1+ years of clinical/hospital experience
Claims Processing experience in a BPO/HMO setting

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:
Ability to multi-task
Ability to pay close attention to detail
Careers with UnitedHealthcare. Work with a Fortune 5 organization that’s serving millions of people as we transform health care with bold ideas. Bring your energy for driving change for the better. Help us improve health access and outcomes for everyone, as we work to advance health equity, connecting people with the care they need to feel their best. As an industry leader, our commitment to improving lives is second to none.

California, Colorado, Connecticut, Nevada, Washington, or New York, Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / Washington / New York / Rhode Island residents is $16.00 – $27.31. 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 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.

Contact Person:
Location: • ,
Application Method: Apply Online
Base Pay: $16.00 - $27.314/hr

Posted on April 06, 2023

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