In collaboration with and supervision by the Registered Dental Hygienist (RDH) Manager and the National Dental Director, the Fair Hearing Appeals RDH, is responsible for providing recommendations for clinical case outcomes determined by a licensed dentist. The Fair Hearing (FH) RDH will attend and represent UnitedHealthcare (UHC) in all Brooklyn Court appearances. Primary Responsibilities: Work as part of an integrated team of the QA team, other functional areas, and members of the UHC C&S Medical appeals staff Receive, gather information, and prepare Fair Hearing packets for the NY C&S Health Plan and others as appropriate for clinical and administrative determinations Communicate with UHC RDH manager and dental directors regarding Fair Hearings Works directly with DDS making the final determination on Clinical cases Attends the Brooklyn Fair Hearings in person and represents UHC. Counsels and educate members and providers regarding adverse determinations and plan benefits Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, and staff training as appropriate Participating in organizational committees, projects, and task forces as appropriate Prepare Evidence packets; collect & compile supporting documentation to support adverse determination and make 3 copies for hearing Prepare waiver packets Travel to & Present evidence packet at Fair Hearings in court Receive Decision & Orders (D&O) from NYS and update outcome status in tracking log Review D &O; Coordinate implementation of directives from Administrative Law Judge Receive compliance inquiries from NYS requesting proof of compliance with D&O Coordinate and compile proof of compliance and draft responses to NYS DOH C&S Dental Medicaid Fair Hearings in-person representation in the Brooklyn Courthouse, as required by the State - This will reduce dental consultant costs, and allow for increased oversight and management of the revised and improved process
Required Qualifications:Registered Dental Hygienist (RDH) with an active, unrestricted license 5 + years clinical practice experience 2+ years of Healthcare or Managed Care experience 2+ years of experience with Microsoft Office (Excel, Word, PowerPoint) Excellent verbal and written communication skills Ability to travel to multiple counties to attend Fair Hearings (Brooklyn County, Nassau County, Suffolk County and Westchester County) Knowledge of NY State Medicaid Dental Regulations Intermediate presentation skills for both clinical and non-clinical audiences Ability to manage multiple tasks and due dates.Preferred Qualifications: Experience with claims coding and review Familiarity with current dental issues and practices Internet researching skillsCareers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do 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. Job Keywords: Keywords: RDH, Dental Hygiene, Hygienist, Appeals, Fair hearing, Dental Appeals, Managed Care, FH, New York Regulations
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.