Clinical Appeals Representative - Cypress, CA

UHG Cypress, CA

About the Job

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.
For those who want to invent the future of Healthcare, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.
Positions in this function are responsible for setting up the Appeals and Grievance cases for the Coordinators, Nurses and Doctors to review for a determination of denial. Position consists of reading and analyzing the member's correspondence and determining what the complaint is which could lead to several different issues. The Clinical Appeals Representative needs to be able to distinguish between Quality of Care, Appeal, Grievances, Expedited, Claims, Referral issues and determining exactly what the member is wanting in their letters. Position involves, calling to obtain the correct information from Member, Medical Groups, Providers and other Departments. Position requires regulatory turnaround times. Accuracy is a very important part of this position.

Primary Responsibilities:
  • Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting)
  • Make outbound calls to members and / or providers to clarify appeal or grievance information
  • Determine where appeal or grievance should be reviewed / handled or route to other departments as appropriate
  • Contact and work with other internal resources to obtain and clarify information
  • Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes and timeframes

Required Qualifications:
  • High School Diploma / GED or higher
  • 6+ months of Telephonic Customer Service experience
  • 35+ wpm typing skills
  • Experience using a computer and Microsoft Office - Microsoft Word (create correspondence and work within templates), Microsoft Excel (data entry, sort, filter, and work within tables), and Microsoft Outlook (email and calendar management)
Preferred Qualifications:
  • Bilingual fluency in English and Spanish
  • Experience in Claims, Managed Care HMO, Doctor's office, and / or Billing
  • Medical Terminology experience
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near - obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.SM

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.

Keywords:  UHG, California, customer service, healthcare, telephonic, patient interaction, field based, advocacy