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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:

Medical and Clinical Operations


United States

Postal Code:


Approximate Salary:

Not Specified

Position Type:

Full Time

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Clinical Appeals Reviewer - LHI - La Crosse, WI

UHG - La Crosse, Wisconsin

Posted: 09/30/2018

At Optum, the mission is clear:  Help people live heathier lives and help make the health system work better for everyone


LHI is one of 4 businesses under OptumServe. OptumServe provides health care services and proven expertise to help federal government agencies modernize the U.S. health system and improve the health and well-being of Americans.

By joining OptumServe you are part of the family of companies that make UnitedHealth Group a leader across most major segments in the U.S. health care system.


LHI was founded in 1999 and acquired by Optum in 2011, LHI specializes in creating and managing health care programs through on-location services, patient-specific in-clinic appointments, telehealth assessments, or any combination based on customer need. LHI's customizable solutions serve the diverse needs of commercial customers, as well as federal and state agencies, including the U.S. Departments of Defense, Veterans Affairs, and Health and Human Services.


There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Ready for a new path? Start doing your life's best work.

Primary Responsibilities:
  • Provide overarching support for the claims process and related activities for the World Trade Center Health Program Nationwide Provider Network
  • Ensuring all World Trade Center Health Program claims are processed in a timely manner with acceptable accuracy. Responsible for the review and resolution of the denied claims from the World Trade Center Health Program Administrator. Must follow up on all denied claims to ensure payment made to LHI.
  • Secondary review of claims approval tasks within MedNet. Also includes, the maintenance of the pended claims file and claims with zero dollars.
  • Provide analysis and reporting on claims level detail.
  • Process daily / weekly claims error files to ensure efficient and expeditious handling of claims
  • Facilitate the code request process with LHI and the World Trade Center Health Program. Tracking of all codes submitted and the response rate of the Health Program.
  • Maintenance of the World Trade Center Health Program code book within MedNet. Provide regular updates to the effected operational departments on new versions of the code book.
  • Submit service code requests for newly added ICD / CPT codes to the contract.
  • Review and process Prior Authorization Level 3 documentation to the World Trade Center Health Program. Communicate decisions from the Health Program to the effected departments.

Required Qualifications:
  • High School Diploma / GED (or higher)
  • 3+ years of medical claims processing experience or equivalent combination of education, experience and / or applicable military experience
  • Strong experience and knowledge of Claims, Medicare / Medicaid guidelines
  • ICD-9, HCPCS / CPT coding, HCFA 1500’s & UB92’s
  • Understanding of claims processing guidelines
  • Medical Terminology
  • Proficient in Microsoft Office Suite including Word (create, edit, save), Excel (create, edit, save), and Outlook (send & receive emails)
Preferred Qualifications:
  • Medical Coding
  • ICD-10
  • Certified Medical Reimbursement Specialist (CMRS) exam completion
  • National Career Readiness Certificate
Soft Skills:
  • Ability to communicate effectively both verbally and in writing
  • Strong organization, planning, interpersonal and multi-tasking skills
  • Must be a self-starter and comfortable with confidential information
  • Attention to detail, strong problem-solving and time-management skills
  • Ability to work in a fast-paced environment, flexible and adaptable to changing situations, and a strong commitment to teamwork
  • Proven skills to establish rapport, trust and confidence with internal departments, staff and external vendors
  • Ability to remain calm in stressful situations and to conduct themselves in a professional manner at all times
  • Must be able to identify and define problems; collect data; establish facts and draw valid conclusions
Careers with LHI. Our focus is simple. We're innovators in cost-effective health care management. And when you join our team, you'll be a partner in impacting the lives of our customers, and employees. We've joined OptumHealth, part of the UnitedHealth Group family of companies, and our mission is to help the health system work better for everyone. We're located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We're supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life's best work.

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: LaCrosse, Customer Service, Medical Coding, Medical Terminology, Appeals, claims

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