You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

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.

The appeals and grievance representative is responsible for investigating and processing appeals and grievances received by veterans or providers. This is a challenging role with serious impact, Specialist work collaboratively with other internal and external functional areas and stakeholders as necessary to resolve the case within the allocated timeframes.

This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 6:00am – 6:00pm EST.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

• Applies knowledge/skills to a range of moderately complex activities.
• Demonstrates great depth of knowledge/skills in own function.
• Sometimes acts as a technical resource to others in own function.
• Proactively identifies solutions to non-standard requests.
• Solves moderately complex problems on own.
• Works with team to solve complex problems.
• Plans, prioritizes, organizes, and completes work to meet established objectives.
• May coordinate work of another team member

Other Responsibilities:

• 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

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 education / GED (or higher) OR equivalent experience
• 2+ years or more experience processing medical and or dental claims
• 1+ years of experience with PCs and Microsoft office, including Outlook (calendar management, sending correspondence), Word (drafting, sending and saving documents), Excel (basic formulas, creating and sending spreadsheets) and Power Point (creating, sending and saving presentations)

Telecommuting Requirements:

• 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

• Ability to work independently

Careers with Optum . Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, Washington or New York, Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / Washington / New York / Rhode Island residents is $22.45 - $43.89.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.

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