Appeals Representative – Remote in CA

If you are located within the state of California, you will have the flexibility to telecommute* (work from home) as you take on some tough challenges.  

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.  

Let’s talk about diplomacy. Let’s talk about accuracy. Let’s talk about how United Health Group became a Fortune 6 leader in health care. We did it by working to become an undisputed leader in creating quality service and helping to improve the lives of millions. Now, here’s where you come in. You can build on your problem solving skills by taking on responsibility for reviewing, researching, investigating and triaging claims that were denied to determine their correct status. You’ll drive the action and communicate with appropriate parties regarding appeals and grievance issues. In turn, we’ll provide you with the great training, support and opportunities you’d expect from a Fortune 6 leader.

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 7am – 3:30pm. 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:

• Research and resolve written complaints submitted by consumers and physicians/providers
• Ensure complaint has been categorized correctly
• Obtain additional documentation required for case review
• Review case to determine if review by clinician is required
• Render decision for non-clinical complaints using sound, fact-based decision making
• Complete necessary documentation of final appeals or grievance determination using appropriate templates
• Communicate appeal or grievance information to members or providers and internal/external parties within the required timeframes

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
• Must be 18 years or older
• 1+ year of experience working in managed care claims in provider appeals and formal dispute
• 1+ years Medical Terminology experience
• Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
• Typing skills due to high volume of data entry (40 words per minute)
• Proficiently skilled in the application and use of Windows Microsoft Word
• Microsoft Excel
• Microsoft Outlook.
• Ability to work 8am-4:30pm PST

Preferred Qualifications:

• 1+ years customer service experience in a healthcare facility

Telecommuting Requirements: 

• Reside within the state of 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. 

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