External Audit Appeal Analyst

This position is National Remote. You’ll enjoy the flexibility to telecommute
* from anywhere within the U.S. as you take on some tough challenges.

At United Healthcare, 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.

• Support Appeals & Grievances external audits with a focus on documenting company claim and appeal processes.
• Assess and interpret external audit requests; identify solutions to non-standard requests and problems.
• Plan, manage, and support external audit appeal sample file production projects, coordinate work amongst team.
• Work independently and with minimal guidance; be a problem solver with exceptional organizational skills.
• Identify, document, and evaluate process and compliance risks escalating as needed to ensure remediation.
• Provide explanations and information to others; serve as subject matter expert internally and externally.
• Research, track, and respond to examiner inquiries; communicate complex issues in a simple, understandable, and digestible format.
• Collaborate with team members and business partners to meet external audit needs, utilizing data analysis and subject matter expertise to influence without authority.
• Professional presentation skills in a virtual forum appropriate for internal and external audiences.

• High School Diploma / GED OR equivalent work experience
• Must be 18 years of age OR older
• 4 years of appeals processing experience, including:
• An understanding of the difference between member and provider appeals, clinical and administrative reviews, and upheld vs. overturned decisions
• The ability to document full claims and appeals history / lifecycle by leveraging the appropriate systems (ETS, ATS, Doc
  360, claim platforms (i.e., UNET, FACETS, COSMOS), ISET, iCUE, ORS, MACESS, Maestro, etc.) to gather information, reviewing sources of truth (SOPs, SPDs, COCs, operational policies, administrative and clinical guidelines, etc.) and leveraging relationships with the supported business functions to get additional details where needed
• Experience with Adobe Professional including an understanding of basic PDF functionalities like the ability to save and print documents to Adobe PDF, using basic markup tools and the ability to collaborate using comments functions
• Experience with Microsoft Excel including the ability to filter, sort, create and edit spreadsheets; execute basic formulas; data entry and formatting
• Experience with Microsoft Outlook including the ability to manage email and calendar, and schedule meetings
• Experience with Microsoft Teams including the ability to create and manage channels, tag individuals and teams, share documents, and post announcements
• Ability to work Monday – Friday, either in any of our 8-hour or 4×10-hour shift schedules during our normal business hours of 6:00am – 5:00pm local time zone (the schedule could be flexible as long as employees work the hours per business need), including the flexibility to work occasional overtime or weekends, based on the business need

• 2 years of UHC claims processing experience; inpatient, outpatient, Rx, dental / vision, etc
• Additional experience with Adobe Professional including; the ability to create, edit (including redaction), organize, and compress files into Adobe PDF binders; and the ability to navigate documents and apply / edit Adobe PDF bookmarks
• Experience with Microsoft PowerPoint including the ability to create and edit power point presentations
• Microsoft Excel skills plus the ability to create charts, graphs, pivot tables, conditional formatting, perform data validation, and advanced data analysis

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information…