November 5, 2024

Optum

San Juan

FULL TIME

Appeals Representative - San Juan, PR

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

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. This position will communicate with appropriate parties regarding appeals and grievance issues, implications and decisions. In addition, analyze and identifies trends for all appeals and grievances.

Primary Responsibilities:

Manage and resolve healthcare appeals work type in accordance with regulatory guidelines, client policies, and internal standards. Ensure timely resolution to meet required deadlines
Collect, review, and validate supporting documentation for appeals. Conduct thorough research to ensure accurate and fair case resolutions
Share and submit reports on case status, resolution times, and appeal to supervisors and other relevant stakeholders
Triage requests and determine the type of work received
Determine where specific appeals should be reviewed/handled, or routed to other departments
Classify and set up the case in the appeals system
Ensure accurate data entry based on research
Ensure all required documentation exists before proceeding with the appeal
Identify and obtain additional information needed to make an appropriate determination
Determine if appeal review is clinical or administrative
Research and make appropriate decisions on administrative cases
Coordinate with business partners to obtain decisions when appropriate
Review member benefit information, provider specific information/contracts, claims, applicable SOPs, nuance grid, delegation status, state specific and national policies and procedures in order to make accurate decision on the case
Ensure correct letter template is utilized and complete template with appropriate information and rationale
Select correct attachment and/or enclosure(s) and add to letter template
Send out completed and timely written notification letter within appeal requirements
May make verbal outreaches to providers/members
Prioritize work based on due date and run applicable work list reports to monitor workload
Plan, prioritize, organize, and complete work to meet established and required timeframes
Solve moderately complex problems on own
Employees are required to complete all work within the required timeframes and ensure all written and verbal communications are completed timely, accurately, and professionally
Supervision guidance may be needed for higher level tasks
Meet quality and productivity expectations
May coordinate work of other team members
Other duties may apply

*** ENGLISH PROFICIENT ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***

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:

1+ years of experience in a production environment
Experience in an office setting environment using the telephone and computer as the primary instruments to perform job duties
Experience with Microsoft Tools: Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports)
Bilingual proficiency in English & Spanish (verbal and written)
Ability to work 40 hours / week during standard business operating hours Monday - Friday from 8am - 8pm AST (It may be necessary, given the business need, to work occasional overtime on weekends and holidays)

Preferred Qualifications:

Experience working or triaging appeals
Experience with ISET, ICUE and/or LINX
Behavioral Health claims experience
Familiarity with Managed Behavioral Health terminology

At United Health 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: United Health 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.

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