28 days old

Appeals and Grievance Liaison - Lexington, KY Tethered Telecommute

Lexington, KY 40507 Work Remotely
  • Job Code

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.

As an Appeals Coordinator/Appeals and Grievance Liaison - we will depend on you to communicate some of our most critical information to the correct individuals regarding appeals and grievance issues, implications and decisions. You will support teams with reviewing, researching, and understand how a claim was processed and why it was denied. You will need a high degree of follow through, attention to detail, and proficiency with verbal and written communication.

This position is full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8 hour shift schedules during our normal business hours of (8:30am-4:30pm). It may be necessary, given the business need, to work in office as well as occasional overtime or weekends. 

What we do defines who we are. Take a deeper look at how we're providing support during this global health crisis and search for a way you can get involved. View our Covid-19 Resources Page at: https://info.uhg.com/

Primary 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 determinations
  • 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
  • Identify and obtain additional information needed to make an appropriate determination
  • Ensure that members obtains a full and fair review of their appeal or grievance
  • Utilize appropriate claims processing systems to ensure that the claim is processed appropriate
  • Make appropriate determinations about whether a claim should be approved or denied based on available analyses/research of claims information
  • Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response letters, Customer Service documentation)
  • Communicate appeal or grievance information to appellants (e.g., members, providers) within the required timeframe (e.g., DOL, DOI)
  • Communicate appeal or grievance issues/outcomes to all appropriate internal or external parties (e.g., providers, regulatory agencies, plan administrators, etc.)
  • Understand and adhere to applicable federal/state laws and regulations (e.g., DOI, DOL, URAC, ERISA, HIPAA, Healthcare Reform/PPACA, CMS)
  • Maintain confidentiality of member appeal or grievance information per relevant regulations and guidelines (e.g., HIPAA)
  • Understand and adhere to applicable documentation handling policies and regulations (e.g., document security, retention)

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.



Posted: 2020-08-24 Expires: 2020-10-08

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Appeals and Grievance Liaison - Lexington, KY Tethered Telecommute

UnitedHealth Group
Lexington, KY 40507

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