Appeals & Grievances Coordinator - Remote in NM

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

As an Appeals & Grievances Coordinator(A&G) - you will be the health plan representative responsible for managing complex member grievances and appeals, including coordination of requests for state fair hearings. The G&A manager is qualified by training and experience to process and resolve grievances and appeals and is responsible for the grievance system. Will live and work in New Mexico.

This is full-time position which requires residency in the state of New Mexico.

If you are located in New Mexico, you’ll enjoy the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Analyze/research/understand how a service/procedure/authorization was processed and why it was denied/modified
• Obtain relevant medical records to submit appeals or grievance for additional review, as needed
• Leverage appropriate resources to obtain all information relevant to the claim modified or denied service
• Obtain/identify contract language and processes/procedures relevant to the appeal or grievance
• Manage all appeals and grievance concerns and priorities within the UHC Turquoise Care Population
• Work with applicable business partners to obtain additional information relevant to the denied/modified service (e.g. Utilization Management/Prior Authorization)
• Ensure that members obtain a full and fair review of their appeal or grievance
• Track and manage requests for all State Fair Hearings; attend and submit evidence regarding cases
• Notify members of determination who have Expedited Appeals; when applicable
• Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response letters, Customer Service documentation)
• Acts as liaison with regulatory agencies regarding member grievances and appeals
• Understand and adhere to applicable documentation handling policies and regulations (e.g., document security, retention)
• Perform as a solid independent contributor
• Assist with validation of monthly/quarterly State appeal and grievance reporting

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:

• 2+ years of experience with appeals, grievances and member complaints
• Ability to compose written correspondence free of grammatical errors while also translating medical and insurance expressions into simple terms that members can easily understand
• Client-facing experience or customer service background
• Reside in the state of New Mexico
• Ability to travel up to 10% throughout the state of New Mexico

Preferred Qualifications:

• Experience with Medicaid and managed care
• Experience working with state partners
• Health plan experience
• Experience gathering documentation and presenting case facts to Administrative Law Judge at state fair hearings

• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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.
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.