Appeals Representative Associate – Ontario, CA

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Description: 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.

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 8:00 am – 5:00 pm. It may be necessary, given the business need, to work occasional overtime. Our office is located at 3990 Concours, Ontario, CA. Employees are required to work some days onsite and 2- 3 days from home.

We offer weeks of on-the-job training. The hours of the training will be based on schedule or will be discussed on your first day of employment.

 

If you are within commutable distance to the office at Ontario, CA, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.

 

Primary Responsibilities:

• Applies knowledge/skills to basic, repeated activities.
• Demonstrates minimum depth of knowledge and skills in own function.
• Responds to standard requests.
• Requires assistance in responding to non-standard requests.
• Solves routine problems by following established procedures.
• Others prioritize and set deadlines for employee.
• Works with others as part of a team.
• Analyze/research/understand how a claim was processed and why it was denied -Obtain relevant medical records to submit appeals or grievance 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 determinations
• 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
• Ensure that members obtains a full and fair review of their appeal or grievance
• Utilize appropriate claims processing systems to ensure that the claim is processed appropriate
• 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 (e.g., DOL, DOI)
• Communicate appeal or grievance issues/outcomes to all appropriate internal or external parties (e.g., providers, regulatory agencies, plan administrators, etc.)

 

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 education or equivalent experience.
• Must be 18 years of age or older
• 6+ months claim processing functions including investigations, negotiating settlements, payments and research regarding eligibility experience
• 1+ year Microsoft Word, Microsoft Excel, Microsoft Adobe experience
• Ability to work any shift between the hours of 8:00 AM – 5:00 PM, including the flexibility to work occasional overtime and weekends based on business need. Employees are required to work some days onsite and 2- 3 days from home.

 

Telecommuting Requirements:

• Reside within commutable distance to the office at 3990 Concours Ontario, CA
• 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.

 

 

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy  

 

California, Residents Only: The hourly range for this is $16.00 – $28.27 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). 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.

 

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