October 19, 2011 (last updated 3 hours 17 min ago)
Position Description: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. Position Responsibilities:
* Maintains a good understanding and interpretation of plan language of all plan benefits for assigned customer accounts including all product lines.
* Reviews appeals based on priority basis by completion of expected turnaround time and in compliance with DOL regulations to avoid penalties/fines.
* Completes a backend Quality Review by checking specific Plan language, verifying benefit information and reviewing bill copy for accuracy of Patient, Date of Service, dollar amount, CPT codes, and Provider name.
* Reviews all documentation in specific system applications.
* Recognizes when to refer claims to our compliance and/or legal department that have potential to become a legal/financial risk.
* Recognizes concerns involving medical judgment issues and refers to Registered RN and determines what additional medical documentation is necessary and requests such information prior to referral. Makes the appeal determination and generates a resolution letter and finalizes all documents related to an appeal review by closing out the database entries.
* Makes sure the letter has all the correct information to be DOL and HIPAA compliant by including specific wording to Appeal Levels, number of days to file, and where to file as outlined in each of the specific Plans.
* Maintains operations by following policies and procedures according to DOL and HIPAA regulations. Maintains customer confidence and protects operations by keeping information confidential.
* Provides the very best customer service to claimants, customers, providers of service and internal personnel concerning appeal reviews.
* Communicates with appropriate parties regarding appeals issues, implications and decisions.
* Analyzes and identifies trends for appeals and may research and resolve written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians/providers.
* Production and quality standards must be met on a daily and monthly basis
UnitedHealthcare Employer & Individual is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
When you work with UnitedHealthcare Employer & Individual, what you do matters. It*s that simple...and it*s that challenging.
In providing consumer-oriented health benefit plans to millions of people, our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.
Regardless of your role at UnitedHealthcare Employer & Individual, the support you feel all around you will enable you to do what you do with energy, integrity, and confidence. So take the first step in what is sure to be a fast paced and highly diversified career.
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