Appeals Representative

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.

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 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends. Our office is located at 2720 N Tenaya Way, Las Vegas, NV.

We offer weeks of on-the-job training. The hours of training will be during our core business hours.

Primary Responsibilities:

• 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
• Research Information Related to Claims Appeals or Grievances
• Analyze/research/understand how a claim was processed and why it was denied
• Obtain relevant medical records to submit appeals or grievances for additional review, as needed. Leverage appropriate resources to obtain all information relevant to the claim
• Identify and obtain additional information needed to make an appropriate determination
• Obtain/identify contract language and processes/procedures relevant to the appeal or grievance
• Work with applicable business partners to obtain additional information relevant to the claim (e.g., Network Management, Claim Operations, Enrollment, Subrogation)
• Determine whether additional appeal or grievance reviews are required (e.g., medical necessity), and whether additional appeal rights are applicable
• Determine where specific appeals or grievances should be reviewed/handled, and route to other departments as appropriate
• Process Claims Appeals or Grievances
• Ensure that members obtain a full and fair review of their appeal or grievance
• Utilize appropriate claims processing systems to ensure that the claim is processed appropriately
• Make appropriate determinations about whether a claim should be approved or denied based on available analyses/research of claims information
• Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response letters, Customer Service documentation)
• Communicate appeal or grievance information to appellants (e.g., members, providers) within the required timeframe
• Communicate appeal or grievance issues/outcomes to all appropriate internal or external parties (e.g., providers, regulatory)

This is a challenging role with serious impact. You’ll need strong analytical skills and the ability to effectively interact with other departments to obtain original claims processing details. You’ll also need to effectively draft correspondence that explains the claim resolution/outcome as well as next steps/actions for the member.

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 equivalent work experience
• Must be 18 years of age OR older
• 1+ years of experience analyzing and solving appeals in the health care industry
• Experience with Microsoft Office including Microsoft Word, Excel, and Outlook
• Ability to work any of our 8-hour shift schedules during our normal business hours of 8:00am - 5:00pm, including the flexibility to work occasional overtime or weekends, based on the business need

Preferred Qualifications:

• Previous experience creating resolution letters
• Experience utilizing claims platform FACETS
• Experience with health care, medical, or pharmacy terminology experience
• Experience in healthcare coding practices (e.g., CPT's, HCPCS, DRG, ICD-9, ICD-10)
• Experience with healthcare business segments (e.g., Commercial, Behavioral Health)

Soft Skills:

• Research and analytical skills
• Excellent written communication skills including advanced skills in grammar and spelling

Nevada Residents Only: The hourly range for this role is $16.54 to $32.55 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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).