You'll join a high caliber team where you're assisting, educating, problem - solving and resolving tenuous situations to the best possible outcomes. Bring your people skills, emotional strength and attention to detail. In return we offer the latest tools and most intensive training program in the industry. Get ready to start doing your life's best work.(sm)
This position falls within our Community & State Appeals and Grievances Department. You will consult with staff, including but not limited to QM (Quality Manager), Provider relations staff, Medical Management (including Prior Authorization), Member services, and Compliance / Legal.
Primarily you will be assigning cases, tracking / trending inventory, and hearing volumes. You will also analyze this data. Position performs claims, provider network, and State regulator contract and rules research and data mining. Position is responsible for the timely and accurate investigation of Grievance System administrative and compliance with State contracts requirements. Accordingly, to investigate, file creation, attending staffing for member grievances and appeals and provider claims disputes.
Helps in data and report (trending) preparation to meet health plan and State timeliness requirements.
Review of incoming mail, logging and assigning cases to coordinators
Facilitating and preparing for weekly & monthly SFH (State Fair Hearing) meetings to include agenda, copies, invites
Prepare for review, responses to subpoenas, garnishments, record requests, liens, etc.
Familiarity with Federal and State laws, regulations, including A.A.C. Title 9, Chapters 34, State Medicaid policies, procedures, reimbursement, etc.
Maintain internal logs and prepare reports for health plan management and meeting State submission requirements.
Assist in developing, implementing and timely preparing system reports and analysis.
Investigate member appeals to assist in rendering timely and accurate decisions within AHCCCS - mandated criteria and within production and quality standards.
Schedule and assist in preparation of witness (e.g., Medical Director) and arrange for appearance / telephonic requests of witnesses as well as exhibit gathering.
Assists in preparation for and presentation of Medicaid grievances and claim disputes towards timely resolution, up to and including, in administrative hearings on government - funded managed health care programs: AHCCCS, DDD, Evercare and CRS matters.
Conduct pre - administrative hearing investigation for appeals and claim disputes, document the findings (in the appeal files), help identify common factors as to whether appeal or claim dispute is a candidate for settlements and assist in settlement negations, as needed.
Assists with filing Grievances and Appeals / Claim Dispute / request State Fair Hearing process; distinguishing between an inquiry, a Grievance, an Appeal, a Claim Dispute and a quality of care issue and know how to triage, resolve or refer incoming calls/correspondence to appropriate personnel.
Docket hearing notices, contact State / Office of Administrative hearings, establish duties and time - frames in connection with each hearing and disseminate information with follow - up as appropriate.
Provide testimony on behalf of the health plan and administrative hearing and represent the health plan at hearing when necessary and appropriate.
Assists with internal segment and external vendor coordination, e.g., third - party liability, lien, primary insurance / coordination of benefit issues, questions.
UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.
We are committed to introducing innovative approaches, products and services that can improve personal health and promote healthier populations in local communities. Our core capabilities... in clinical care resources, information and technology uniquely enable us to meet the evolving needs of a changing health care environment as millions more Americans enter a structured system of health benefits and we help build a stronger, higher quality health system that is sustainable for the long term.
We serve our clients and consumers through two distinct platforms:
?UnitedHealthcare, which provides health care coverage and benefits services.
?Optum, which provides information and technology-enabled health services.