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Telephonic Clinical Appeals Reviewer - San Francisco, CA or Maryland Heights, MO or Atlanta, GA

UnitedHealth Group

San Francisco, CA
Job Code:
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Job Details

Telephonic Clinical Appeals Reviewer - San Francisco, CA or Maryland Heights, MO or Atlanta, GA(Job Number:732265)

Position Description:

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.

Positions in this function are responsible for providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances. Communicates with appropriate parties issues, implications and decisions. Analyzes and identifies trends for appeals and grievances. This includes senior level positions with education / certification / licensure other than an RN, such as BSW, MSW, DDS, Chiropractor, Physical Therapist, etc. (Positions responsible for claims appeals can be found in the Claims job family.)

Primary Responsibilities:

  • Provide Phone Support to drive resolution of caller Questions / Issues
  • Develop and Maintain Productive Relationships / Interactions with Callers
  • Familiar with Business / Industry concepts and terminology as pertains to appeals and grievances
  • Provide Consulting / Education on Caller Issues / Trends as pertains to Appeals and grievances
  • Resolve member service inquiries related to member and provider appeals and grievances
  • Process telephone inquiries regarding: Basic appeal rights, Appeals status, General process, Basic complaints, Urgent appeals
  • Triage calls to determine call type and transfer to the appropriate department as necessary
  • Refax letters to providers and facilities, as necessary
  • Ensure accurate documentation of calls
  • Identify requests for escalation / complaints and escalate accordingly
  • Route identified issues to the appropriate site, as necessary
  • Manage calls efficiently and effectively
  • Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow - up with the member / provider / facility
  • Research complex issues across multiple databases and work with support resources to resolve inquiry
  • Participate in special projects, work groups or committees as assigned
  • Other duties as assigned

Job Clinical Appeals
Primary Location US-CA-San Francisco
Other Location US-GA-Atlanta, US-MO-Maryland Heights
Organization Optum Ops-PHM Utilization Mgmt
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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