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Clinical Appeals Representative - Cypress, CA

Company: UnitedHealth Group
Location: Chino Hills
Posted on: September 21, 2023

Job Description:

If you are located within a commutable distance of Cypress, CA, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.
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 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, Monday - Friday. Employees are required to work any 8-hour shift between the hours of 6:00 AM - 5:00 PM including the availability to work occasional overtime based on business need.--
We offer 3 - 4 weeks of peer - to - peer training.
This position requires at the least 3 days a week and may telecommute when not in the office if meets Telecommuting requirements.
Our office is located at 5701 Katella Avenue, Cypress, CA, 90630. Employees will be required to work at least 3 days onsite and some days from home.
*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 OR equivalent
  • Ability to type at the speed of 35+ WPM (words per minute)
  • Experience with using Microsoft Office: Microsoft Word, Microsoft Excel, and Microsoft Outlook (ability to create, copy, edit, send, and save documents, spreadsheets, and correspondence)
  • Ability to work onsite at least 3 days a week--at the Cypress, CA office and may telecommute when not in the office if meets Telecommuting requirements
  • Ability to work any 8-hour shift between the hours of 6:00 AM - 5:00 PM from Monday - Friday including the availability to work occasional overtime based on business need
    Preferred Qualifications:
  • Experience in Claims, Managed Care HMO, Doctor's office, and / OR Billing
  • Medical Terminology experience
    Telecommuting Requirements:
  • Reside within a commutable distance of Cypress, CA
  • 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
    Soft Skills:
  • Knowledge of scanning documents on a printer
    California Residents Only: The salary range for California residents is $16.00 - $27.31. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
    At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
    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: UnitedHealth Group, Chino Hills , Clinical Appeals Representative - Cypress, CA, Healthcare , Chino Hills, California

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