Combine two of the fastest - growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making Healthcare data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life’s best work.
The Clinical Review and Resolution, Resolution and Appeals Divisional Claims Manager is primarily responsible for the following, but not limited to:
• Lead Equian CRR on all legal efforts that support the Forensic Review, including all verbal and written communications with internal and/or external parties.
• Management and successful closure of claims that require client involvement
• May also have an assignment of other claims and is responsible, for guiding these claims to a successful close.
• Serve as Clinical Review and Resolution Subject Matter Expert (“SME”) and acts as a trainer / mentor for the CRR business.
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
We offer 8-10 weeks of paid training. The hours during training will be 8:00am to 5:00pm, Monday - Friday.
Training will be conducted virtually from your home.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
- All Provider Manual and Reimbursement Policy reviews,
- All Legal Discovery / investigation work for support of FRR,
- All CRR business liability strategies and/or high liability escalations with both the Client and Provider (includes their necessary travel and representing the Company and Client)
- Providing Clients, a supported template response to Providers inquiries regarding adjustments (e.g., Clean Claim / Prompt Pay Language)
- Interact with both internal and external Counsel as needed to support FRR
- Lead the resolution effort for assigned claims, including all verbal and written communications with clients, facilities, and third parties, to include returning calls and emails in a timely manner
- Provide analysis and recommendations to client, based on client-specific guidelines and provider information, to apply an optimal resolution strategy for outstanding issues, including the identified adjustments, application of out-of-network discounts, appeal timeline, facility guidelines, and any other appropriate parameters
- Coordinate and interact with the Clinical, Appeals, Account Management, Operations Management, and Legal teams as needed throughout the Resolution and/or Appeals process
- Adhere to Key Performance Indicators as implemented by the Director of Resolution, Appeals and Quality Division
- Update and document claim status, notes, and information in Equian systems and ensure documentation is accessible to others also working on the claim (for example, HANDS, Clinical Point, etc.)
- Maintain open communication with client on resolution matters in accordance with client’s requirements to obtain a resolution that is acceptable to the client
- Coordinate updating the Forensic Review Report and related documents and systems to ensure the revised adjustments are reflected in the record for accounting purposes; includes facilitating revisions to Forensic Review Reports, updates to accounting fields, and/or claim related documentation
- Communicate client issues, as warranted, with the assigned Account Manager, Account Coordinator, Appeals, and any other individuals also involved in the issue
- Coordinate with the Finance department on accounts receivable issues, including credit memos, allowed adjustments, and any other issue that affect the savings and fee of the claim
- Act as consultant to the Appeals and the Resolution Departments and assist with work assignments as requested
- Attend and participate in provider calls as requested by Account Management or other teams
- Participate in updating proprietary policies and procedures as applied by the Clinical team for claim reviews
- Participate in the review of Client Provider Manuals, Reimbursement/Payment Policies and/or Medical Policies when warranted
- Lead and identify and escalate claims throughout Resolution and/or Appeals process
- Assist RAD team members as Divisional SME with work assignments as requested
- Travel to provider or client meetings, as warranted
- Understand, maintain, and always apply HIPAA privacy and security standards
- Apply Company’s business rules and regulations to all interactions with clients, facilities, and third parties
- Contribute to development of and enhancements to the Company’s business systems
- Contribute to development of and enhancements to the Company’s process improvements
- Participate / Contribute to legal / regulatory investigations as warranted
- Participate in department, Company, and client meetings as required
- Serve as a Company CRR SME
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.
- Bachelor’s Degree
- 3+ years of progressive business experience preferably in a healthcare managed care administration environment
- Demonstrated success in the areas of provider relations, claim negotiation and resolution required.
- If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders
- Medical coding, paralegal or nursing accreditations preferred
- Appeals experience
UnitedHealth Group is an essential business. The health and safety of our team members is our highest priority, so we are taking a science driven approach to slowly welcome and transition some of our workforce back to the office with many safety protocols in place. We continue to monitor and assess before we confirm the return of each wave, paying specific attention to geography-specific trends. At this time, 90% of our non - clinical workforce transitioned to a work at home (remote) status. We have taken steps to ensure the safety of our 325,000 team members and their families, providing them with resources and support as they continue to serve the members, patients and customers who depend on us.
You can learn more about all we are doing to fight COVID-19 and support impacted communities at: https://www.unitedhealthgroup.com/newsroom/addressing-covid.html
Careers with OptumInsight. Information and technology have amazing power to transform the Healthcare industry and improve people's lives. This is where it's happening. This is where you'll help solve the problems that have never been solved. We're freeing information so it can be used safely and securely wherever it's needed. We're creating the very best ideas that can most easily be put into action to help our clients improve the quality of care and lower costs for millions. This is where the best and the brightest work together to make positive change a reality. This is the place to do your life’s best work.
Colorado Residents Only: The salary range for Colorado residents is $64,800 to $116,000. Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary, UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance.
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.
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