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Job Details

Telephonic Clinical Appeals Reviewer - San Francisco CA

Company name
Optum, Inc.

San Francisco, CA

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Position Description:

Energize your career with one of Healthcares fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, its a dream that definitely can come true. Already one of the worlds leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader.

Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation and Performance.

Positions in this function are responsible for providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances. Communicates with appropriate parties issues, implications and decisions. Analyzes and identifies trends for appeals and grievances. This includes senior level positions with education / certification / licensure other than an RN, such as BSW, MSW, DDS, Chiropractor, Physical Therapist, etc. (Positions responsible for claims appeals can be found in the claims job family.)

Primary Responsibilities:

Provide Phone Support to drive resolution of caller Questions / issues

Develop and maintain productive relationships / interactions with callers

Familiar with business / industry concepts and terminology as pertains to appeals and grievances

Provide consulting / education on caller issues / trends as pertains to appeals and grievances

Resolve member service inquiries related to member and provider appeals and grievances

Process telephone inquiries regarding: Basic appeal rights, appeals status, general process, basic complaints, urgent appeals

Triage calls to determine call type and transfer to the appropriate department as necessary

Refax letters to providers and facilities, as necessary

Ensure accurate documentation of calls

Identify requests for escalation / complaints and escalate accordingly

Route identified issues to the appropriate site, as necessary

Manage calls efficiently and effectively

Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow-up with the member / provider / facility

Research complex issues across multiple databases and work with support resources to resolve inquiry

Participate in special projects, work groups or committees as assigned

Other duties as assigned

Required Qualifications:

High School Diploma / GED or higher

Comfortable working Monday- Friday between hours of 8 :00am to 5:00pm PST

1 years of Telephonic Customer Service

1 years of Healthcare Insurance experience

Experience using a computer and Microsoft Office: MicrosoftWord,MicrosoftExcel, andMicrosoftOutlook (with the ability to create, edit, save and send documents and spreadsheets)

Preferred Qualifications:

Familiarity with Medical Terminology

Experience with claims

Any college experience

Soft Skills:

Demonstrated experience utilizing communication skills both verbal and written in a professional setting

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So, when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.

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, San Francisco, CA, customer service, healthcare, telephonic, patient interaction, appeals and grievances, call center

Company info

Optum, Inc.
Website :

Company Profile
We’re passionate about serving, connecting and improving the whole health system for everyone in it. Optum™ is a health services and innovation company on a mission to help make the health system work better for everyone. We combine data and analytics with technology and expertise to power modern health care. In collaboration with our partners, we focus on three key drivers of transformative change: modernizing the health system infrastructure, advancing care and empowering consumers. Serving the whole system Partnering with 300 health plans to ensure positive changes take root in the broader health system and benefit the most possible people. Supporting hundreds of life sciences companies as they research and develop new treatments. Working with 67,000 pharmacies to help people get the care and treatments they need. Helping half of the Fortune 500 employers meet their employees’ health and wellness needs Serving care providers and health systems — including four out of five U.S. hospitals — to support their focus on quality care, better patient experiences, operational efficiency and cost savings. Partnering with government agencies in 40 states and, increasingly, around the world. Helping 74 million people find the right care at the best value, understand their options and take charge of their health and wellness. We are inspired to always work harder, aim higher, and deliver on our values of integrity, compassion, relationships, innovation and performance for everyone we serve. We never forget that, ultimately, the work we do has an impact on the lives of real people every day. From sharing new discoveries to celebrating healthy victories, see the latest news and events to learn how Optum is collaborating with our partners and communities to help make the health system work better for everyone. Powering modern health care requires a special team – people who envision a healthier future, people who challenge the status quo and people who are driven by compassion and possibility. If you want your work to make a powerful difference in the lives of others, explore an Optum career today.

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