Appeals Representative - San Juan, PR

Taleo; San Juan (PR); On-site; USD 36,000 - 48,000; Full time

Job summary

UnitedHealth Group in San Juan, Puerto Rico seeks an Appeals Specialist to review and resolve healthcare appeals. You will collect documentation, determine case type (clinical or administrative), and coordinate with partners to ensure timely, accurate decisions.

The role requires English/Spanish bilingual proficiency and 40-hour weekly availability, with potential overtime. Responsibilities include data entry, reporting, and preparing written notifications, while meeting quality and productivity

Qualifications

• 1+ years of experience in a production environment.
• Experience in an office setting environment using the telephone and computer as the primary instruments to perform job duties.
• Experience with Microsoft Tools: Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports).
• Bilingual proficiency in English & Spanish (verbal and written).
• Ability to work 40 hours / week during standard business operating hours Monday - Sunday from 7am - 7pm AST (It may be necessary, given the business need, to work occasional overtime on weekends and holidays).

Responsibilities

• Manage and resolve healthcare appeals work type in accordance with regulatory guidelines, client policies, and internal standards. Ensure timely resolution to meet required deadlines
• Collect, review, and validate supporting documentation for appeals. Conduct thorough research to ensure accurate and fair case resolutions
• Share and submit reports on case status, resolution times, and appeal to supervisors and other relevant stakeholders
• Triage requests and determine the type of work received
• Determine where specific appeals should be reviewed/handled, or routed to other departments
• Classify and set up the case in the appeals system
• Ensure accurate data entry based on research
• Ensure all required documentation exists before proceeding with the appeal
• Identify and obtain additional information needed to make an appropriate determination
• Determine if appeal review is clinical or administrative
• Research and make appropriate decisions on administrative cases
• Coordinate with business partners to obtain decisions when appropriate
• Review member benefit information, provider specific information/contracts, claims, applicable SOPs, nuance grid, delegation status, state specific and national policies and procedures in order to make accurate decision on the case
• Ensure correct letter template is utilized and complete template with appropriate information and rationale
• Select correct attachment and/or enclosure(s) and add to letter template
• Send out completed and timely written notification letter within appeal requirements
• May make verbal outreaches to providers/members
• Prioritize work based on due date and run applicable work list reports to monitor workload
• Plan, prioritize, organize, and complete work to meet established and required timeframes
• Solve moderately complex problems on own
• Employees are required to complete all work within the required timeframes and ensure all written and verbal communications are completed timely, accurately, and professionally
• Supervision guidance may be needed for higher level tasks
• Meet quality and productivity expectations
• Identify and escape potential compliance risks or concern to leadership, as appropiate.
• Provide timely updates on assigned cases, including current stauts, barriers, and anticipated resolution timelines, to supervisors and other stakeholders as needed.

Skills

Microsoft Word

Microsoft Outlook

Microsoft Excel

Bilingual English/Spanish

Tools

Microsoft Word

Microsoft Outlook

Microsoft Excel

Job description

Improve the lives of others while Caring. Connecting. Growing together.

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Positions in this function are responsible for providing expertise or general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances. This position will communicate with appropriate parties regarding appeals and grievance issues, implications and decisions. In addition, analyze and identifies trends for all appeals and grievances.

Primary Responsibilities:

• Manage and resolve healthcare appeals work type in accordance with regulatory guidelines, client policies, and internal standards. Ensure timely resolution to meet required deadlines
• Collect, review, and validate supporting documentation for appeals. Conduct thorough research to ensure accurate and fair case resolutions
• Share and submit reports on case status, resolution times, and appeal to supervisors and other relevant stakeholders
• Triage requests and determine the type of work received
• Determine where specific appeals should be reviewed/handled, or routed to other departments
• Classify and set up the case in the appeals system
• Ensure accurate data entry based on research
• Ensure all required documentation exists before proceeding with the appeal
• Identify and obtain additional information needed to make an appropriate determination
• Determine if appeal review is clinical or administrative
• Research and make appropriate decisions on administrative cases
• Coordinate with business partners to obtain decisions when appropriate
• Review member benefit information, provider specific information/contracts, claims, applicable SOPs, nuance grid, delegation status, state specific and national policies and procedures in order to make accurate decision on the case
• Ensure correct letter template is utilized and complete template with appropriate information and rationale
• Select correct attachment and/or enclosure(s) and add to letter template
• Send out completed and timely written notification letter within appeal requirements
• May make verbal outreaches to providers/members
• Prioritize work based on due date and run applicable work list reports to monitor workload
• Plan, prioritize, organize, and complete work to meet established and required timeframes
• Solve moderately complex problems on own
• Employees are required to complete all work within the required timeframes and ensure all written and verbal communications are completed timely, accurately, and professionally
• Supervision guidance may be needed for higher level tasks
• Meet quality and productivity expectations\
• Identify and escape potential compliance risks or concern to leadership, as appropiate.
• Provide timely updates on assigned cases, including current stauts, barriers, and anticipated resolution timelines, to supervisors and other stakeholders as needed.

May coordinate work of other team members

• Other duties may apply

*** ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***

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:

• 1+ years of experience in a production environment
• Experience in an office setting environment using the telephone and computer as the primary instruments to perform job duties
• Experience with Microsoft Tools: Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports)
• Bilingual proficiency in English & Spanish (verbal and written)
• Ability to work 40 hours / week during standard business operating hours Monday - Sunday from 7am - 7pm AST (It may be necessary, given the business need, to work occasional overtime on weekends and holidays)

Preferred Qualifications:

• Experience working or triaging appeals
• Experience with ISET, ICUE and/or LINX
• Familiarity with managed behavioral health terminology
• Experience in Medicare, Medicaid, or Commercial Healthcare operations
• Experience with ATS, ISET, ICUE, and/or LINX

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

UnitedHealth Group is a Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

UnitedHealth Group is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need special assistance or accommodation for any part of the application process, please call 1-866-566-8715 to be connected to Recruitment Services. Recruitment Services hours of operation are 7 a.m. to 7 p.m. CT, Monday through Friday.

UnitedHealth Group is a registered service mark of UnitedHealth Group, Inc. The UnitedHealth Group name with the dimensional logo, as well as the dimensional logo alone, are both service marks for the UnitedHealth Group, Inc.

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.