Senior Appeals Representative

This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. 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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. As a Senior Appeals Representative , you will be doing all end - to - end process. Work independently with support for leaders and members. Should be deadline driven and detail oriented, while holding accountability to all actions. Appeals would be assigned to them all day and pivot if needed. Work higher volume but requires less effort and less time spent working it. Employees in this position are responsible for responding, analyzing, and resolving written clinical or administrative appeal requests using the correct process, letter templates, appeal attachments and enclosures within the required timeframes for all level of care for all delegated accounts. This position is full time (40 hours / week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00 am - 6:00 pm local time. It may be necessary, given the business need, to work occasional overtime or weekends. This will be paid on the job training and the hours during training will be 8:00 am to 5:00 pm, Monday - Friday.

Research and resolve written appeals submitted by consumers and physicians / providers Ensure appeals has been categorized correctly Obtain additional documentation required for case review Review case to determine if review by clinician is required Render decision for non - clinical appeals using sound, fact - based decision making Complete necessary documentation of final appeals or grievance determination using appropriate templates Communicate appeal or grievance information to members or providers and internal / external parties within the required timeframes Manage assigned inventory to ensure timely and accurate resolution of cases Must have exceptional multi - tasking skills with the ability to prioritize tasks This 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 act as a subject matter expert for your team on applicable regulatory guidelines and privacy policies. You'll also need to effectively draft correspondence that explains the claim resolution / outcome as well as next steps / actions for the member. 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 with analyzing and solving appeals and grievances OR 2+ years of experience in a healthcare setting with knowledge of claims and / OR claims adjustments Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications Ability to work any of our full time (40 hours / week), 8-hour shift schedules during our normal business hours of 7:00 AM - 6:00 PM local time from Monday - Friday. It may be necessary, given the business to work occasional overtime or weekends.

Behavioral claims OR appeals