Job Description

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

The Appeals & Grievances Manager is responsible for providing oversight of member grievance appeals, provider appeals or request for State Fair Hearing. This Manager may serve in a project manager capacity for smaller work efforts as well.

This position can be located in either Greensboro or Raleigh, NC. You will work in the local office and from home as needed.

Primary Responsibilities:

* Serve as a central point of contact for the NC DHHS for appeals and grievances
* Provide oversight to the provider and member appeals organization
* Ensure A&G department processes all appeals and grievances in accordance with required turnaround times and other contractual requirements
* Monitor appeals and grievances and provide senior management with monthly reporting on trends
* Ensure that all appeals and grievances are being processed and investigated according to contractual requirements
* Work with state partners on grievance and appeals as needed
* Ensure federal and state law changes are being integrated appropriately
* Provide solutions and work with cross functional teams to ensure problems are corrected around the appeal and grievance process
* Escalate issues to department leadership for support and guidance
* Perform analysis, and evaluate downstream business systems, processes, and/or organizational impacts with A&G issues
* Assist in the development of new reports and testing, provide ongoing support of existing solutions
* Provide ownership and oversight for A&G 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:

* 3+ years of experience in quality improvement, analysis development, appeals and grievance, and / or state fair hearings
* Experience managing or supervising others
* Experience presenting information and responding to questions from internal and external stakeholders
* Intermediate or higher level of proficiency in Microsoft Office and products (Word, Excel, Outlook) and able to learn new software tools quickly
* If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders

Preferred Qualifications:

* Solid assessment and documentation skills
* Detailed oriented, able to independently organize and manage multiple tasks
* Highly organized
* Self-motivated and able to work with a wide variety of individuals and possess the ability to negotiate effectively in working with teams and other departments
* Possess strong leadership skills and able to be effective in getting tasks done while working through cross functional teams

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 health care here. We serve the health care 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 health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)

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

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.

Job Keywords: Appeals and Grievances, Quality, Manager, Provider, Clinical, Medicaid, Health Plan, Greensboro, Raleigh, NC, North Carolina, Telecommute, Telecommuting, Telecommuter, Work From Home, Remote