Job Specifications
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts on the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
The Dispute and Appeals Manager will adjudicate member grievances and appeals, including coordination of requests for state fair hearings. The Dispute and Appeals Manager is qualified by training and experience to process and resolve grievances and appeals and is responsible for the grievance system.
This is a fast-paced working environment that requires the ability to multitask with attention to detail and excellent organizational skills.
If you are located in Massachusetts, Connecticut, New Hampshire or Rhode Island, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities
The Appeals and Grievance Analyst roles and responsibilities include:
Analyze/research/understand data related to how a service/procedure/authorization for denied/modified and appealed services including clinical documentation
Obtain relevant medical records (authorization, claims and clinical) related to appeals for state review
Leverage appropriate resources to obtain all information relevant to state request
Obtain/identify contract language and processes/procedures relevant to the denials and appeals
Work with applicable business partners, shared services to obtain additional information relevant to the denied/modified service (eg Utilization Management/Prior Authorization)
Acts as liaison with regulatory agencies regarding member denials, appeals and state audits
Understand and adhere to applicable documentation handling policies and regulations (eg, document security, retention)
Develop, assist and support Director of operation and Chief Data Officer with analytics for state reports as needed
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications
SQL basic certification
2+ years of experience with state appeals and denials audits for Medical and Medicaid home care services
2+ years of experience in reporting & analysis, data management & reconciliation
2+ years of experience in using Excel as a reporting and analysis tool
1+ years of experience gathering documentation for state fair hearings
1+ years of experience utilizing 2 of the following: SQL, PowerBI, and/or SMART relational database tools
1+ years of work experience in a corporate setting, preferably healthcare-based corporation/managed care organization
Intermediate level of proficiency with Microsoft Office applications
Intermediate level of familiarity and fluency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications including but not limited to claims, clinical care management, authorization, enrollment, cloud base, etc.
Ability to work Monday - Friday and flexibly outside core hours, including evenings and weekends, per business needs
Resident of Massachusetts or Rhode Island or New Hampshire, or Connecticut Preferred Qualifications
Experience with Medicare and/or Medicaid and managed care in a variety of health care settings
Experience working with state partners
Experience working in a member facing role
Proven ability to remain focused and productive each day though tasks may be repetitive
Proven ability to multi-task, including the ability to understand multiple products and multiple levels of benefits within each product
Analysis within managed care/health insurance industry, government programs and/or finance
Experience with healthcare claims, financial and care management data
Basic level of proficiency with Power BI/Tableau/Talend/Crystal Reports
Experience tracking, trending, and reporting on metrics with visualization
Experience with Medicaid/Medicare claims and financial data Soft Skills
Proven ability to compose written correspondence free of grammatical errors while also translating medical and insurance expressions into simple terms that members can easily understand
An analytical problem-solving mindset - the ability to demonstrate key successes on business solutions derived from analysis and deep learning
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all be
About the Company
UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone. We are 340,000 colleagues in two distinct and complementary businesses working to help build a modern, high-performing health system through improved access, affordability, outcomes and experiences. Optum delivers care aided by technology and data, empowering people, partners and providers with the guidance and tools they need to achieve better health. UnitedH...
Know more