Appeals Representative - Las Vegas, NV

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
Research Information Related to Claims Appeals or Grievances
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 determination
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 CAP
Process Claims Appeals or Grievances
Identify and obtain additional information needed to make an appropriate determination
Ensure that members obtain 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

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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 OR equivalent years of work experience
  Must be 18 years of age or older
  1+ years of experience analyzing and solving appeals in the health care industry
  Experience with Microsoft Office including Microsoft Word (create correspondence and work within templates), Microsoft Excel (ability to sort and filter), and Microsoft Outlook (email and calendar management)
  
• Ability to work any of our 8-hour shift schedules during our normal business hours of (8:00am - 5:00pm). It may be necessary, given the business need, to work occasional overtime
  Ability to work overtime mandated to process expedited appeals within 72 hours as required by department
  
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  Preferred Qualifications:
  
  
  Experience utilizing claims platform FACETS
  Experience with creating resolution letters
  Experience with health care, medical, or pharmacy terminology experience
  Experience in healthcare coding practices (e.g., CPT's, HCPCS, DRG, ICD-9, ICD-10)
  Experience with healthcare business segments (e.g. Commercial, Behavioral Health)
  
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  Soft Skills:
  

  
  Research and analytical skills
  Written communication skills including advanced skills in grammar and spelling
  
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  The hourly range for this role is $16.88 to $33.22 per hour based on full-time employment. 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.
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  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.
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  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.
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  UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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  #RPO #RED

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