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Clinical Appeals Reviewer - Cypress, CA

UnitedHealth Group


Location:
Cypress, CA
Date:
05/26/2017
Job Code:
1751554
Apply on the Company Site
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Job Details


Clinical Appeals Reviewer - Cypress, CA(Job Number:716163)
Description

Position Description:

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.

Positions in this function are responsible for reviewing, researching, investigating, and triaging all types of appeals and grievances. Communicates with appropriate parties regarding appeals and grievance issues

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. Employees in jobs labeled with SCA must support a government Service Contract Act (SCA) agreement.

Primary Responsibilities:
  • Ensure complaint has been categorized correctly
  • Determine and confirm member eligibility and benefits
  • Obtain additional documentation required for case review
  • Place relevant documents into image repository
  • Initiate outbound contact to members or providers
  • Review case to determine if review by Clinician is required
  • Research and resolve written complaints submitted by consumers and physicians/providers
  • Render decision for non-clinical complaints using sound, fact-based decision making
  • Draft verbiage for use in outbound correspondence
  • Prioritize and organize tasks to meet compliance deadlines
  • Ability to meet established productivity, schedule adherence, and quality standards
  • Experience in HMO health plans a plus
  • Moderate work experience within own function
  • Some work is completed without established procedures
  • Basic tasks are completed without review by others
  • Supervision/guidance is required for higher level tasks

Job Clinical Appeals
Primary Location US-CA-Cypress
Other Location 
Organization Clinical Appeals & Grievances
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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