Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life's best work.(sm)
The Medical Claims Review Coordinator provides support to the UM department in administrative functions for UM organization determinations and appeal coordination. This position utilizes knowledge of Medicare and state HMO guidelines in order to facilitate and comply with the Utilization Management plan in data entry and to prepare letters utilizing standard templates. The Associate Patient Care Coordinator will also provide float coverage for the central UM department, utilizing and following established policies and procedures.
Provides data entry, filing, tracking time frames and status of case files and mailing letters to patients and providers
Reviews denials and determines whether the decisions are retro/ claims DOS or prospective DOS, and whether they are NCB or medically necessary. Sorts appropriately
Monitors system approval queues and prints member letters, ensuring that all approvals are printed and mailed by end of business day
Prepares envelopes and letters for mailing according the UM policy
Receives appeal requests from health plans and/ or QIO, logs requests, researches and provides requested information
Works with claims department to redirect claims related appeal requests
Generates reports for analysis by department using the data entry system
Assists with CMS organization determination reports as needed
This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. You also must be able to work a flexible schedule that includes evening hours and Saturdays.
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.
High School diploma or GED
2+ years of customer service experience
Experience with MS Word, Excel and Outlook
Sound knowledge of medical terminology
Proficient software computer skills
Possess planning, organizing, conflict resolution, negotiation and interpersonal skills
Independent problem identification / resolution and decision making skills
Ability to interact with individuals and with multidisciplinary teams
Ability to demonstrate excellent customer service with patients, providers, and health plan and interacting with other internal departments within the organization
You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role
Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi - specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
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.
Job Keywords: Medical Claims Review Coordinator, San Antonio, TX, Texas
Unitedhealth Group Inc.