POSITION DESCRIPTION

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. SM APPEALS REPRESENTATIVE is a challenging role with serious impact. You'll need strong analytical skills and the ability to effectively interact with other departments to obtain original claims processing details. You'll also need to effectively draft correspondence that explains the claim resolution / outcome as well as next steps / actions for the member.

Primary Responsibilities:

• Review patient files and utilize knowledge and skills as well as knowledge of payer requirements to determine if medical or dental claim is adjudicated correctly.

• Proficiently read and understand information from patient medical records, claims history and DOL / State regulations.

• Processing of medical and dental claims.

• Re - Price medical claims using PPO Network's on-line systems/tools

• Utilize criteria and other resources and clinical evidence to develop sound and well - supported documentation for review decisions

• Coordinate drafting and mailing of letters related to member appeals

• Prepare feedback and participate in meetings

• Obtaining information by telephone as well as by hard copy and entering into the computer systems

• Prioritization of individual work flow associated with the case assignments

• Establishing and maintaining professional rapport with clients and providers (physicians and hospitals)

• Maintaining and assuring accuracy of documentation

• Meet and/or discuss with members, clients and providers the issues relating to claim administration

• Ability to report to the office

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.

CAREERS AT UNITEDHEALTHCARE EMPLOYER & INDIVIDUAL. We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of health care. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is YOUR LIFE'S BEST WORK. SM 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.

Required Qualifications:

• High School Diploma / GED (or higher)
• Experience working with Microsoft Office including Microsoft Word (ability to create, edit and save documents), Microsoft Excel (ability to create, edit and save spreadsheets) and Microsoft Outlook (ability to create, edit and send correspondences)

Preferred Qualifications:

• Previous experience interpreting benefits
• Previous experience in processing medical, dental and vision claims

Soft skills:

• Effective organizational and prioritization skills
• Excellent oral and written communication skills
• Ability to work in a fast paced multi - tasking environment
• Strong interpersonal skills with ability to function as a positive team member

A Fortune 6 company, we're focused on helping people live healthier lives while making the health system work better for everyone. Here, we seek to empower people with the information, guidance and tools to make personal health choices. We work harder and we aim higher. We expect more from ourselves and each other. And, at the end of the day, we’re doing a lot of good for more than 142 million people worldwide.