Clinical Appeals Representative - National Remote

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

As a Clinical Appeals Representative, you will be expected to constantly meet established productivity, schedule adherence, and quality standards while maintaining good attendance. You will receive Care Coordination notification cases for non - clinical assessment / intervention and provide appropriate triage; determine benefit coverage issues based on employer group contracts; set up / documents / triages cases / send them to Triage RN to determine Urgency; ensure 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 with Managers and / or Supervisors available to assist with questions. You may make some outbound calls but would be receiving no inbound calls. You will need to be able to multitask and toggle between numerous systems (such as ICUE, ETS, ECAA, ISET, Outlook, Teams, SharePoint) to perform your daily job functions.

This position is full - time (40 hours / week), Monday - Friday. Employees are required to work any 8-hour shift between the hours of 9:00 AM - 6:00 PM CST including the flexibility to work occasional overtime, 1 Sunday per month, and 2 holidays per year based on business need.

We offer weeks of paid training. The hours during training will be discussed. Length of time is dependent on new hire and is ongoing. Training will be conducted virtually from your home.

• 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
• 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

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)
• 6+ months of Appeals experience in a healthcare setting
• Computer proficiency in operating Microsoft Office applications, including Microsoft Word (reading, reviewing, and updating documents), Microsoft Excel (reading and sorting data), Microsoft PowerPoint (reading slides), and Microsoft Outlook (managing calendars and mailboxes)
• Ability to work any 8-hour shift between the hours of 9:00 AM - 6:00 PM CST from Monday - Friday including the flexibility to work occasional overtime, 1 Sunday per month, and 2 holidays per year based on business need

Preferred Qualifications:

To avoid fraudulent job postings, you need to keep in mind some important tips when applying for jobs online. Be wary of job postings that require you to work from home without proper training or equipment, as these are often signs of a fraudulent job opportunity. Keep your finances safe by avoiding job postings that require you to use your personal bank account. A job posting that only offers email or text message interviews should be approached with caution. Beware of job listings that require you to purchase a 'starter kit' or other materials before you can start working. Trust your instincts and don't be afraid to walk away from a job posting that seems suspicious. Consider using a separate email account for job-related communications to keep your personal and professional correspondence organized and secure. Researching the company's supply chain and logistics can help you understand its efficiency and operational excellence before applying for any job. Reach out to the company to verify the job posting's authenticity and ensure that they are hiring.

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

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• 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

California, Colorado, Connecticut, Nevada, New Jersey, New York, Washington, or Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / New Jersey / New York / Washington / 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.

#RPO #GREEN