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Dispute and Appeals Analyst
About the position
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts 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 Analyst will work collaboratively with member grievances and appeals staff to support timely decisions. Will support health plan staff with coordination of requests for state fair hearings. The Dispute and Appeals Analyst is qualified by training and experience to process and assist with resolution of grievances and appeals. This is a fast-paced working environment that requires the ability to multitask with attention to detail and excellent organizational skills. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.
Responsibilities
- Analyze/research/understand how a service/procedure/authorization was processed and why it was denied/modified
- 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 modified or denied service
- 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, shared services, providers and members to obtain additional information relevant to the denied/modified service
- 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
- Ensure that members obtain a full and fair review of their appeal or grievance
- Document final determination of appeals or grievances using appropriate templates, communication processes, etc.
- Completes member, provider and regulatory grievances and appeals cases within the specified time frame
- Prepares grievance and appeals cases for presentation to triage and resolution teams
- Works with internal departments to resolve grievances and appeals
- Acts as liaison with regulatory agencies regarding member grievances and appeals
- Understand and adhere to applicable documentation handling policies and regulations
- Assist with validation of monthly/quarterly State appeal and grievance reporting
- Attend and participate at State meetings
Requirements
- 2+ years of experience with appeals, grievances and member complaints
- Experience gathering documentation and presenting case facts to Administrative Law Judge at state fair hearings
- Beginning to intermediate experience in Microsoft Office applications
- Familiarity and fluency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
- 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
- Ability to work Monday - Friday with flexibly outside core hours, including evenings and weekends, per business needs
Nice-to-haves
- 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
- Ability to work standard hours aligned with the Eastern Time Zone
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
