Clinical Appeals Representative

This position follows a hybrid schedule with three (3) in-office days per week (potentially more). Our office is located at 5701 Katella Ave., Cypress, CA 90630.

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.

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 : 00 am - 5 : 00 pm PST. It may be necessary, given the business need, to work occasional overtime. Employees are required to work at least 3 days onsite (potentially more) and may be able to work some days from home.

We offer 2-3 weeks of paid training. The hours during training will be 8 : 00 am - 5 : 00 pm PST, Monday - Friday. Training will be hybrid, some days in the office and some days at home.

Primary Responsibilities :

• Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting)
• Enter appeals and grievances details within the system and audit against provided documentation
• 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 timeframe

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 :

Preferred Qualifications :

Telecommuting Requirements :

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $16.00 - $27.69 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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