Job Description

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts on 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.
The Dispute and Appeals Manager will adjudicate member grievances and appeals, including coordination of requests for state fair hearings. The Dispute and Appeals Manager is qualified by training and experience to process and resolve grievances and appeals and is responsible for the grievance system.
This is a fast-paced working environment that requires the ability to multitask with attention to detail and excellent organizational skills.
If you are located in Massachusetts, Connecticut, New Hampshire or Rhode Island, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
The Appeals and Grievance Analyst roles and responsibilities include:

• Analyze/research/understand data related to how a service/procedure/authorization for denied/modified and appealed services including clinical documentation
• Obtain relevant medical records (authorization, claims and clinical) related to appeals for state review
• Leverage appropriate resources to obtain all information relevant to state request
• Obtain/identify contract language and processes/procedures relevant to the denials and appeals
• Work with applicable business partners, shared services to obtain additional information relevant to the denied/modified service (e.g. Utilization Management/Prior Authorization)
• Acts as liaison with regulatory agencies regarding member denials, appeals and state audits
• Understand and adhere to applicable documentation handling policies and regulations (e.g., document security, retention)
• Develop, assist and support Director of operation and Chief Data Officer with analytics for state reports as needed

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:

• SQL basic certification
• 2+ years of experience with state appeals and denials audits for Medical and Medicaid home care services
• 2+ years of experience in reporting & analysis, data management & reconciliation
• 2+ years of experience in using Excel as a reporting and analysis tool
• 1+ years of experience gathering documentation for state fair hearings
• 1+ years of experience utilizing 2 of the following: SQL, PowerBI, and/or SMART relational database tools
• 1+ years of work experience in a corporate setting, preferably healthcare-based corporation / managed care organization
• Intermediate level of proficiency with Microsoft Office applications
• Intermediate level of familiarity and fluency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications including but not limited to claims, clinical care management, authorization, enrollment, cloud base, etc.
• Ability to work Monday - Friday and flexibly outside core hours, including evenings and weekends, per business needs
• Resident of Massachusetts or Rhode Island or New Hampshire, or Connecticut

Preferred Qualifications:

• Experience with Medicare and/or Medicaid and managed care in a variety of health care settings
• Experience working with state partners
• Experience working in a member facing role
• Proven ability to remain focused and productive each day though tasks may be repetitive
• Proven ability to multi-task, including the ability to understand multiple products and multiple levels of benefits within each product
• Analysis within managed care/health insurance industry, government programs and/or finance
• Experience with healthcare claims, financial and care management data
• Basic level of proficiency with Power BI / Tableau / Talend / Crystal Reports
• Experience tracking, trending, and reporting on metrics with visualization
• Experience with Medicaid / Medicare claims and financial data

Soft Skills:

• Proven ability to compose written correspondence free of grammatical errors while also translating medical and insurance expressions into simple terms that members can easily understand
• An analytical problem-solving mindset - the ability to demonstrate key successes on business solutions derived from analysis and deep learning

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
For more information on our Internal Job Posting Policy,
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 salary for this role will range from $58,800 to $105,000 annually 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.
#RPO #GREEN

Skills Required