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Company Name : UnitedHealth Group
Location : Cypress, CA 90630
Position : Clinical Appeals Representative – Work from Home
Job Description : If you are located within PST/MST, you will have the flexibility to telecommute* (work from home) as you take on some tough challenges.
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 . SM
Positions in this function are responsible for setting up the Appeals and Grievance cases for the Coordinators, Nurses and Doctors to review for a determination of denial. Position consists of reading and analyzing the member’s correspondence and determining what the complaint is which could lead to several different issues. The Clinical Appeals Representative needs to be able to distinguish between Quality of Care, Appeal, Grievances, Expedited, Claims, Referral issues and determining exactly what the member is wanting in their letters. Position involves, calling to obtain the correct information from Member, Medical Groups, Providers, and other Departments. Position requires regulatory turnaround times. Accuracy is a very important part of this position.
This position is full-time (40 hours/week) Monday – Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00am – 5:00pm PST. It may be necessary, given the business need, to work occasional overtime. Our office is located at 5701 Katella Avenue, Cypress, California 90630.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
Primary Responsibilities:
Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting)
Make outbound calls to members and/or providers to clarify appeal or grievance information
Determine where appeal or grievance should be reviewed / handled or route to other departments as appropriate
Contact and work with other internal resources to obtain and clarify information
Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes, and timeframes
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
High School Diploma / GED (or higher)
6+ months of Telephonic Customer Service experience
35+ WPM typing skills
Ability to use Microsoft Office – Microsoft Word (create and edit correspondence), Microsoft Excel (ability to create, edit, and sort spreadsheets, basic analytical formulas (VLOOKUP, if), and Microsoft Outlook (email and calendar management)
Ability to work Monday – Friday, 8-hour shifts during core business hours of 8:00am – 5:00pm PST
Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state, and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.
Preferred Qualifications:
Medical Terminology experience
Bilingual fluency in English and Spanish
Experience in Claims, Managed Care HMO, Doctor’s office, and / or Billing
Telecommuting Requirements:
Reside within PST/MST
Required to have a dedicated work area established that is separated from other living areas and provides information privacy
Ability to keep all company sensitive documents secure (if applicable)
Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.
Military & Veterans find your next mission: We know your background and experience is different and we like that. UnitedHealth Group values the skills, experience and dedication that serving in the military demands. In fact, many of the values defined in the service mirror what the UnitedHealth Group culture holds true: Integrity, Compassion, Relationships, Innovation and Performance. Whether you are looking to transition from active duty to a civilian career, or are an experienced veteran or spouse, we want to help guide your career journey. Learn more at https://uhg.hr/transitioning-military
Learn how Teresa, a Senior Quality Analyst, works with military veterans and ensures they receive the best benefits and experience possible. https://uhg.hr/vet
Careers with UnitedHealthcare . Let’s talk about opportunity. Start with a Fortune 10 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 wherever 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.
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