Senior Clinical Appeals Reviewer - Appeals Team - San Diego, CA / San Francisco, CA

Unitedhealth Group Inc. San Diego , CA 92140

Posted 2 months ago

Energize your career with one of Healthcare's fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true. Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader.

Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation and Performance.

Primary Responsibilities:

  • Triage requests into correct categories

  • Document request as A & G Correspondence or A & G Appeal

  • Operate with high attention to detail when performing various data entry tasks

  • Prioritize work based on due date and run applicable work list reports to monitor workload

  • Plan, prioritize, organize and complete work to meet assigned deadlines

  • Determine if appeal is clinical or administrative and ensure correct letter template is utilized

  • Select, update and send department specific attachments and / or enclosure(s)

  • Send out written notification as indicated under appeals policies compile IRO packets

  • Solve moderately complex problems individually or in a team setting

  • Work on high level tasks under management supervision / guidance

  • Adhere to state and federal guidelines with processing appeals

  • Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral Health, Medical claims / appeal management processes

Required Qualifications:

  • High School Diploma / GED (or higher)

  • 1 years of Medical / Behavioral Health Appeal & Grievance experience

  • 1 years of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook with the ability to create, edit, save and send documents

  • 6 months of Claim UM (Utilization Management) experience

  • Strong data entry skills

  • Must live in or near one of the following locations: San Diego, CA or San Francisco, CA

Preferred Qualifications:

  • Experience with ISET, IQ and / or UMR

  • Familiarity with Medical Terminology

  • Medical Claims experience

Soft Skills:

  • Must have exceptional multi-tasking skills with the ability to prioritize tasks

  • Ability to handle a fast pace, deadlines, and competing priorities

  • Effective interpersonal skills, flexibility and ability to handle change

  • Ability to work independently as well as a member of the team

  • Excellent verbal, written, computation and organizational skills

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So, when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.

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.

Keywords: UHG, San Diego,CA, customer service, healthcare, telephonic, Triage, claims, appeals


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Senior Clinical Appeals Reviewer - Appeals Team - San Diego, CA / San Francisco, CA

Unitedhealth Group Inc.