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Resolution and Appeals Divisional Escalation Manager- Remote

Company: UnitedHealth Group
Location: Hartford
Posted on: September 20, 2022

Job Description:

You ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Combine two of the fastest - growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making Healthcare data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life s best work. SM

This position is full-time (40hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8am - 5pm. It may be necessary, given the business need, to work occasional overtime.

All Telecommuters will be required to adhere to UnitedHealth Group s Telecommuter Policy.

The Itemized Bill Review, Resolution and Appeals Divisional Escalation Manager is primarily responsible for the following, but not limited to:

  • Lead Equian Itemized Bill Review on all liability efforts that support the Forensic Review, including all verbal and written communications with internal and/or external parties.
  • Management and successful closure of escalated claims that require client involvement
  • May also have an assignment of other claims and is responsible, for guiding these claims to a successful close.
  • Serve as Itemized Bill Review escalated Subject Matter Expert ("SME") and acts as a trainer / mentor for the Itemized Bill Review business. Claims Resolution/Negotiation/Documentation/Complex Claim Support
    • All CRR business liability strategies and/or high liability escalations with both the Client and Provider (includes their necessary travel and representing the Company and Client)
    • Providing Clients, a supported template response to Provider s inquiries regarding adjustments (e.g. Clean Claim / Prompt Pay Language)
    • Lead the resolution effort for escalated claims, including all verbal and written communications with clients, facilities, and third parties, to include returning calls and emails in a timely manner
    • Provide analysis and recommendations to client, based on client-specific guidelines and provider information, to apply an optimal resolution strategy for outstanding issues, including the identified adjustments, application of out-of-network discounts, appeal timeline, facility guidelines, and any other appropriate parameters
    • Coordinate and interact with the Clinical, Appeals, Account Management, Operations Management, and Legal teams as needed throughout the Resolution and/or Appeals process
    • Adhere to Key Performance Indicators as implemented by the Director of Resolution, Appeals and Quality Division
    • Update and document claim status, notes, and information in Equian systems and ensure documentation is accessible to others also working on the claim (for example, HANDS, Clinical Point, etc.)
    • Maintain open communication with client on resolution matters in accordance with client s requirements to obtain a resolution that is acceptable to the client
    • Coordinate updating the Forensic Review Report and related documents and systems to ensure the revised adjustments are reflected in the record for accounting purposes; includes facilitating revisions to Forensic Review Reports, updates to accounting fields, and/or claim related documentation
    • Communicate client issues, as warranted, with the assigned Account Manager, Account Coordinator, Appeals, and any other individuals also involved in the issue
    • Act as consultant to the Appeals and the Resolution Departments and assist with work assignments as requested
    • Attend and participate in escalated provider calls as requested by Account Management or other teams
    • Participate in updating proprietary policies and procedures as applied by the Clinical team for claim reviews
    • Participate in the review of Client Provider Manuals, Reimbursement/Payment Policies and/or Medical Policies when warranted
    • Lead and identify and escalate claims throughout Resolution and/or Appeals process
    • Assist RAD team members as Divisional SME with work assignments as requested
    • Travel to provider or client meetings, as warranted Other:
      • Understand, maintain, and always apply HIPAA privacy and security standards
      • Apply Company s business rules and regulations to all interactions with clients, facilities, and third parties
      • Contribute to development of and enhancements to the Company s business systems
      • Contribute to development of and enhancements to the Company s process improvements
      • Participate / Contribute to legal / regulatory investigations as warranted
      • Participate in department, Company, and client meetings as required
      • Serve as a Company CRR SME 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.

        Required Qualifications:
        • Juris Doctorate or RN Degree; emphasis in healthcare billing, accounting, finance, law or business administration.
        • 5+ years of progressive business experience in a healthcare managed care administration environment.
        • Demonstrated success in the areas of provider relations, claim negotiation and resolution.
        • 8 + years of experience in medical billing/coding
        • 8 + years of experience in Appeals/Health Insurance Regulatory Affairs
        • Knowledge of medical and insurance terminology
        • Experience in lead position Preferred Qualifications:
          • Familiarity with medical terminology and coding
          • Advanced computer skills, specifically Microsoft Excel Telecommuting Requirements:
            • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
            • Ability to keep all company sensitive documents secure (if applicable)
            • Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service Soft Skills:
              • Strong organizational skills, attention to detail, and ability to prioritize
              • Excellent analytical skills
              • Ability to multi-task and work with little direction. A self-starter.
              • Excellent verbal and written communication skills.
              • Proven strategic negotiation skills.
              • Strong organizational skills, attention to detail and ability to prioritize.
              • Ability to multi-task and work with little direction.
              • Team player demonstrating enthusiasm and commitment to Company vision and mission.
              • Strong customer service and relationship building skills. UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

                Military & Veterans find your next mission: We know your background and experience is different and we like that. UnitedHealth Group values the skills, experience and dedication that serving in the military demands. In fact, many of the values defined in the service mirror what the UnitedHealth Group culture holds true: Integrity, Compassion, Relationships, Innovation and Performance. Whether you are looking to transition from active duty to a civilian career, or are an experienced veteran or spouse, we want to help guide your career journey. Learn more at

                Learn how Teresa, a Senior Quality Analyst, works with military veterans and ensures they receive the best benefits and experience possible.

                Careers with OptumInsight. Information and technology have amazing power to transform the Healthcare industry and improve people's lives. This is where it's happening. This is where you'll help solve the problems that have never been solved. We're freeing information so it can be used safely and securely wherever it's needed. We're creating the very best ideas that can most easily be put into action to help our clients improve the quality of care and lower costs for millions. This is where the best and the brightest work together to make positive change a reality. This is the place to do your life s best work. SM

                Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $66,100 - $118,300. The salary range for Connecticut / Nevada residents is $72,800 - $129,900. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you ll find a far-reaching choice of benefits and incentives

                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.
                ..... click apply for full job details

Keywords: UnitedHealth Group, Hartford , Resolution and Appeals Divisional Escalation Manager- Remote, Executive , Hartford, Connecticut

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