Dispute and Appeals Manager - Remote in Idaho

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts 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.

Primary Responsibilities:

The Dispute and Appeals Manager roles and responsibilities include:

• Analyze/research/understand how a service/procedure/authorization was processed and why it was denied/modified
• 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 modified or denied service
• Identify and obtain additional information needed to make an appropriate determination
• Obtain/identify contract language and processes/procedures relevant to the appeal or grievance
• Work with applicable business partners, shared services, providers and members to obtain additional information relevant to the denied/modified service (e.g. Utilization Management/Prior Authorization)
• 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 obtain a full and fair review of their appeal or grievance
• Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response letters, Customer Service documentation)
• Completes member, provider and regulatory grievances and appeals cases within the specified time frame
• Prepares grievance and appeals cases for presentation to triage and resolution teams
• Works with internal departments to resolve grievances and appeals
• Acts as liaison with regulatory agencies regarding member grievances and appeals
• Understand and adhere to applicable documentation handling policies and regulations (e.g., document security, retention)
• Assist with validation of monthly/quarterly State appeal and grievance reporting
• Attend and participate at State meetings

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.

Required Qualifications:

• 2 years of experience with appeals, grievances and member complaints
• Experience gathering documentation and presenting case facts to Administrative Law Judge at state fair hearings
• Beginning to intermediate experience in Microsoft Office applications
• Familiarity and fluency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
• 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
• Ability to work Monday - Friday and flexibly outside core hours, including evenings and weekends, per business needs
• Resident of Idaho

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

• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

The salary range for this role is $59,500 to $116,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

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.