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. 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.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.Primary Responsibilities:Helps in data and report (trending) preparation to meet health plan and State timeliness requirements.Review of incoming mail, logging and assigning cases to coordinatorsFacilitating and preparing for weekly and monthly SFH (State Fair Hearing) meetings to include agenda, copies, invitesPrepare 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 requirementsAssist in developing, implementing and timely preparing system reports and analysisInvestigate member appeals to assist in rendering timely and accurate decisions within AHCCCS-mandated criteria and within production and quality standardsSchedule and assist in preparation of witness (e.g., Medical Director) and arrange for appearance / telephonic requests of witnesses as well as exhibit gatheringAssists 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 mattersConduct 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 neededAssists 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 personnelDocket 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 appropriateProvide testimony on behalf of the health plan and administrative hearing and represent the health plan at hearing when necessary and appropriateAssists with internal segment and external vendor coordination, e.g., third-party liability, lien, primary insurance / coordination of benefit issues, questionsOther duties as assigned by manager
Required Qualifications:High School Diploma / GEDAbility to work within standard business hours of 8:00 AM - 5:00 PM, Monday - Friday with the flexibility to work evenings or weekends as business needs arise3+ years of experience in either State Fair Hearing (SFH) or Appeals and Grievances3+ years of advanced professional reporting experience within Microsoft Excel including the ability to easily create pivot tables, VLOOKUP, and work with large data sets1+ years of experience preparing professional, data-driven narrative reports for all staff levels1+ years of experience utilizing Microsoft Word (create and edit documents) and Microsoft Outlook (send, receive emails, and manage calendar) Preferred Qualifications:State Fair Hearing (SFH) experience or exposureExperience tracking and analyzing dataBachelor's Degree (or higher)Experience managing incoming court documentsExperience managing work queue or assigning work to a team of 5 or greaterSoft Skills:Strong organizational and analytical skillsAbility to balance conflicting prioritiesAbility to communicate in a concise, professional manner Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in healthcare here. We serve the healthcare needs of low income adults and children with debilitating illnesses such as Cardiovascular Disease, Diabetes, HIV/AIDS and High-risk Pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive Healthcare, Community, and Government partners to heal healthcare and create positive change for those who need it most. This is the place to 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.Keywords: UHG, UHC, Analyst, Appeals & Grievances, State Fair Hearing, SFH, data analysis
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.