What are the responsibilities and job description for the Senior Clinical Appeals Reviewer position at UnitedHealth Group?
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
Senior Clinical Appeals Reviewer are responsible to do Clinical Appeals investigation and review on highly escalated issues related to FWAE or Recovery operations including, but not limited to, executive leadership/regulatory affairs complaints, DOIs, Medical Society complaints, member balance billing, provider refusal to treat, media threats, legal issues involving provider counsel or supporting UHG internal counsel and other issues requiring administrative (clinical/coding) re-reviews, provider education and other FWAE inquiries.
- Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so
Required Qualifications:
- Medical degree - BHMS/BAMS/BUMS/BPT/MPT/B.Sc. Nursing (Medical Graduates only)
- 1.5 years of experience in Clinical Investigation Process W&E
- Knowledge of Clinical Waste and Error
- Knowledge of CPT/diagnosis codes, CMC guideline
- Proven good verbal and written communication skills with attention to detail & Quality focused
Preferred Qualifications:
- Health Insurance knowledge, managed care experience
- Claims processing experience
- Medical record familiarity
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.
