Positions in this function are responsible for reviewing, researching, investigating, and triaging all types of appeals and grievances and communicating 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 dental providers.
- 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
- 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
High School Diploma / GED (or higher)
- 1+ years of Customer Service experience analyzing and solving customer's problems or 1+ years of experience in an office setting environment using the telephone and computer as the primary instruments to perform job duties
- Ability to create, copy, edit, send, and save in Microsoft Office applications including Word, Excel, and Outlook
Experience utilizing, ETS, FACETS, and ISET
Experience with Dental and Vision terminology on appeals and / or claims
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Keywords: Appeals Representative, Santa Ana, CA, customer service, Word, Excel, Outlook, Dental, Vision, appeals, claims, ETS, FACETS, ISET