Appeals and Grievances Coordinator

This position is Remote in New Mexico. You will have the flexibility to work remotely* as you take on some tough challenges. 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 optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together As an Appeals & Grievances Coordinator (A&G) - you will be the health plan representative responsible for managing complex member grievances and appeals, including coordination of requests for state fair hearings. The G&A manager is qualified by training and experience to process and resolve grievances and appeals and is responsible for the grievance system. Will live and work in New Mexico. This position is full time (40 hours / week), Monday - Friday. Employees are required to have flexibility to work any of our shift schedules during our normal business hours of 8:00 am - 5:00 pm MST. It may be necessary, given the business need, to work occasional overtime.

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 Obtain/identify contract language and processes/procedures relevant to the appeal or grievance Manage all appeals and grievance concerns and priorities within the UHC Turquoise Care Population Work with applicable business partners to obtain additional information relevant to the denied/modified service (e.g. Utilization Management/Prior Authorization) Ensure that members obtain a full and fair review of their appeal or grievance Track and manage requests for all State Fair Hearings; attend and submit evidence regarding cases Notify members of determination who have Expedited Appeals; when applicable Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response letters, Customer Service documentation) 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) Report validation tasks, including reviewing data for accuracy, completeness, consistency, and compliance with applicable state, federal, contractual, and submission requirements Perform as a solid independent contributor Assist with validation of monthly/quarterly State appeal and grievance reporting 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.

High School Diploma / GED OR equivalent work experience Must be 18 years of age OR older 2+ years of experience managing the end-to-end appeals, grievances, OR member complaint resolution process Experience gathering documentation and presenting case facts to Administrative Law Judge at state fair hearings Experience producing clear, grammatically accurate written correspondence and translating complex medical and insurance terminology into easy-to-understand language for members Experience working directly with customers, clients, OR members in a service-oriented environment Proficiency in Microsoft Office applications, including Microsoft Excel, Microsoft Word, Microsoft PowerPoint, and reporting tools Reside in the state of New Mexico Ability to travel up to 10% throughout the state of New Mexico Ability to work full time (40 hours / week), Monday - Friday. Employees are required to have flexibility to