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.
As an Appeals and Denials team member, you will help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.
This position is full-time (40 hours/week) Tu-Sat 11-8p CST. Employees are required to have flexibility to work any of our 8-hour or 10-hour shift schedules during our business hours. It may be necessary, given the business need, to work occasional overtime.
We offer a shift differential for working a minimum of two hours after 6pm in the local time zone. The position includes 4-6 weeks of paid training which may be at an earlier schedule than those listed above. This position requires working four holidays per year on a rotating basis. Employees will receive holiday pay. Opportunities for overtime may be offered based on business needs.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
Ensure timely processing of all denial-related and member-oriented written communications. Ensure all denial information is processed according to protocol and documentation is timely and meets all Federal and State requirements
Ensure second-level reviews have been performed and documented. May confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICCs), Skilled Inpatient Care Coordinators (SICCs), Pre-service Coordinators (PSCs) and facility personnel to ensure denial information is processed timely and appropriately
Serve as a liaison by communicating with internal and external customers including health plans, providers, members, quality organizations, and other colleagues
Document and communicate appeal and denial information via fax, email, or established portal access, including appeal and denial letters, NOMNC letters, AOR forms, and clinical information
Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams
Serve as a liaison for requests for information from QIO or health plan staff
Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management
Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies
Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, punctuation, etc.), as well as the. ability to follow grade-level requirements (including, but not limited to DENC letter, IDN letter, Exhaustion of Benefits letter, Administrative Denial letter, Provider Denial letter)
Review NOMNC for validity before processing appeal requests
Send reviews to Medical Director for rescinding NOMNC when necessary
Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed
Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed
Follow all established facility policies and procedures
Assist with completing pre-service authorization requests to assist the pre-service team as needed
Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs
Perform other duties and responsibilities as required, assigned, or requested
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:
Active, unrestricted registered clinical license in state of residence – Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist
3+ years of clinical experience as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist
Proficient with Windows and Microsoft Office Suite
Demonstrated excellent documentation skills
Demonstrated exceptional verbal and written interpersonal and communication skills
Ability to work four+ holidays per year on a rotating basis
Dedicated, distraction-free workspace and the ability to install high speed internet via DSL/Cable Broadband/Fiber at home
Preferred Qualifications:
Active clinical license
Managed care experience
Experience with utilization management, utilization review, or insurance authorizations
Experience determining levels of care
ICD-10 experience
Familiar with InterQual
Demonstrated understanding of CMS regulations
Demonstrated understanding of the appeal process
Ability to understand medical reviews
Ability to write high-quality member friendly letters with appropriate grammar and spelling
Ability to work the aligned shifts:
Tu-Sat 11-8p CST
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
The hourly range for this role is $34.42 to $67.60 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
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.
UnitedHealth Group
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