Appeals and Grievances Supervisor – San Juan, PR

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.

 

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.

 

Primary Responsibilities: 

• Coordinates, supervises and is accountable for the daily activities of business support, technical or production team or unit
• Provide hands-on support and guidance to ensure timely and accurate resolution of cases
• Create and manage staff schedules, ensuring adequate coverage on weekends and during peak times. Monitor adherence to schedules and adjust as needed based on workload
• Oversee the inventory of active and pending appeals .Ensure proper categorization, prioritization, and tracking of all cases
• Act as the primary point of contact for client escalations that require immediate attention. Collaborate with stakeholders to resolve high-priority cases in a timely manner
• Monitor aged and due cases, ensuring they are addressed promptly. Ensure the team actively works on reducing the backlog of older appeals
• Set clear performance expectations for the team, conduct regular performance reviews, and provide coaching and feedback. Manage KPIs and ensure the team meets or exceeds goals
• Prepare and present reports on case resolution times, aging inventory, and team performance. Identify trends and implement process improvements
• Ensure all appeal and grievance resolutions comply with internal policies, regulatory guidelines, and client-specific requirements. Conduct regular quality audits
• Sets priorities for the team to ensure task completion
• Coordinates work activities with other supervisors
• Develops plans to meet short-term objectives
• Identifies and resolves operational problems using defined processes, expertise and judgment
• Decisions are guided by policies, procedures and business plan
• Other duties may apply

 

***ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION*** 

 

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: 

• 1+ years of leadership experience as a SME, Trainer, Team Lead or Supervisor
• Experience with Microsoft Tools: Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating/editing spreadsheets, filtering, navigating reports)
• Ability to work 40 hours/week during standard business operating hours Monday – Saturday from 7am – 9pm AST
• Ability to perform this role in an office setting or other company location
• English & Spanish proficiency (verbal and written)

 

Preferred Qualifications: 

• 1+ years of experience working in appeals and grievance
• Claims experience
• Proven knowledge of claims processing and/or claims adjustments
• Experience with healthcare/medical terminology, and medical coding
• Demonstrated working knowledge of FACETS, Linx, Qfiniti, Enligthen, ICUE, COSMOS and/or UNET platforms
• Experience working with various payers, such as Medicare, Medicaid, and or Commercial insurance
• Demonstrated exceptional relationship building skills, including effective communication, empathy, adaptability, and the ability to resolve conflicts and build trust

 

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.    

 

 

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

 

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.