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UnitedHealth Group Appeals Represenative Associative in Bangalore, India

Job Profile: Appeals Analyst

Job Function Description

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. Communicates with appropriate parties regarding appeals and

grievance issues, implications and decisions. Analyzes and identifies trends for all appeals and grievances. May research and

resolve written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and


General Job Profile

  • Limited work experience.

  • Works on simple tasks using established procedures.

  • Depends on others for guidance.

  • Work is typically reviewed by others.

Job Scope and Guidelines

  • Applies knowledge/skills to basic, repeated activities.

  • Demonstrates minimum depth of knowledge and skills in own function.

  • Responds to standard requests.

  • Requires assistance in responding to non-standard requests.

  • Solves routine problems by following established procedures.

  • Others prioritize and set deadlines for employee.

  • Works with others as part of a team.

Functional Competency & Description Proficiency Level

CAP_Analyze/Research Information Related to Claims Appeals or Grievances A) Foundational

-Analyze/research/understand how a claim was processed and why it was denied

-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

-Identify and obtain additional information needed to make an appropriate determinations

-Obtain/identify contract language and processes/procedures relevant to the appeal or grievance

-Work with applicable business partners to obtain additional information relevant to the claim (e.g., Network Management, Claim

Operations, Enrollment, Subrogation)

-Determine whether additional appeal or grievance reviews are required (e.g., medical necessity), and whether additional appeal

rights are applicable

-Determine where specific appeals or grievances should be reviewed/handled, and route to other departments as appropriate

CAP_Process Claims Appeals or Grievances A) Foundational

-Identify and obtain additional information needed to make an appropriate determination

-Ensure that members obtains a full and fair review of their appeal or grievance

-Utilize appropriate claims processing systems to ensure that the claim is processed appropriate

-Make appropriate determinations about whether a claim should be approved or denied based on available analyses/research of

claims information

-Document final determination of appeals or grievances using appropriate templates, communication processes, etc. (e.g., response

letters, Customer Service documentation)

-Communicate appeal or grievance information to appellants (e.g., members, providers) within the required timeframe (e.g., DOL,


-Communicate appeal or grievance issues/outcomes to all appropriate internal or external parties (e.g., providers, regulatory

Qualifications :

Any graduates.

1+ year of Customer Service Experience in a call center environment analyzing and solving customer problems OR 1+ year of experience in a Corporate environment

Beginner level of experience with MS Word and Excel.

Ability to work overtime as needed


Experience with Healthcare/Medicare Terminology

Managed Care and previous Appeals/Grievances experience

Experience : - 1-2 Years