Let’s talk about diplomacy. Let’s talk about accuracy. Let’s talk about how UnitedHealth Group became a Fortune 10 company leader in health care. We did it by working to become an undisputed leader in creating quality service and helping to improve the lives of millions. Now, here’s where you come in. You can build on your problem-solving skills by taking on responsibility for reviewing, researching, investigating and triaging claims that were denied determining their correct status. You’ll drive the action and communicate with appropriate parties regarding appeals and grievance issues. In turn, we’ll provide you with the great training, support and opportunities you’d expect from a Fortune 10 company.

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). It may be necessary, given the business need, to work occasional overtime. Our office is located at 2720 N Tenaya Way Las Vegas, NV.

Primary Responsibilities:

• 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 physicians/providers.
• Research Information Related to Claims Appeals or Grievances
• Analyze/research/understand how a claim was processed and why it was denied
• Obtain relevant medical records to submit appeals or grievance for additional review, as needed Leverage appropriate resources to obtain all information relevant to the claim
• Identify and obtain additional information needed to make an appropriate determination
• Obtain/identify contract language and processes/procedures relevant to the appeal or grievance
• Work with applicable business partners to obtain additional information relevant to the claim (e.g., Network Management, Claim Operations, Enrollment, Subrogation)
• Determine whether additional appeal or grievance reviews are required (e.g., medical necessity), and whether additional appeal rights are applicable
• Determine where specific appeals or grievances should be reviewed/handled, and route to other departments as appropriate CAP
• Process Claims Appeals or Grievances
• Identify and obtain additional information needed to make an appropriate determination
• Ensure that members obtain a full and fair review of their appeal or grievance
• Utilize appropriate claims processing systems to ensure that the claim is processed appropriate
• Make appropriate determinations about whether a claim should be approved or denied based on available analyses/research of claims information
• Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response letters, Customer Service documentation)
• Communicate appeal or grievance information to appellants (e.g., members, providers) within the required timeframe (e.g., DOL, DOI)
• Communicate appeal or grievance issues/outcomes to all appropriate internal or external parties (e.g., providers, regulatory

This is a challenging role with serious impact. You’ll need strong analytical skills and the ability to effectively interact with other departments to obtain original claims processing details. You’ll also need to effectively draft correspondence that explains the claim resolution/outcome as well as next steps/actions for the member.

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) OR equivalent years of work experience
• Microsoft Office including Microsoft Word (create correspondence and work within templates), Microsoft Excel (ability to sort, filter, and create simple spreadsheets), and Microsoft Outlook (email and calendar management
• 2+ years of experience analyzing and solving appeals and grievances in the health care industry

Preferred Qualifications:

• Experience with health care, medical, or pharmacy terminology experience
• Experience in healthcare coding practices (e.g., CPT's, HCPCS, DRG, ICD-9, ICD-10)
• Experience utilizing claims platforms (e.g., UNET, COSMOS, Diamond, FACETS, Unison, NICE, Pulse)
• Experience with healthcare business segments (e.g., Medicare and Retirement, Community and State (Medicaid), Commercial, Behavioral Health)
• Previous experience with creating resolution letters

Soft Skills:

• Strong written communication skills including advanced skills in grammar and spelling
• Research and analytical skills

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.

Careers at UnitedHealthcare Employer & Individual . We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of healthcare. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is your life’s best work. SM

Nevada Residents Only: The salary range for Nevada residents is $16.83 - $29.66. 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

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies required all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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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