Denial/Appeals Coordinator - Ontario, CA - Full-time / Part-time

Position Description

Works closely with Utilization Management Departments to generate timely and compliant denial letters and to facilitate the submission of appropriate appeal documentation, according to standards set.  Compiles and maintains denial letter and appeal files for keeping and storage, as indicated.  Responsible for reporting of appeals and denials to Utilization Management/Compliance/QI.

Essential Responsibilities and Functions:

• Once a denial is issued, responsible for development and timely submission of denial letters, within the set parameters of NAMM California and contracted Health Plans.  These letters include, but are not limited to: denials generated for acute inpatient services, denied pre-authorization requests and changes in level of care.


• Works closely with UM/QI/Compliance to insure that denial letters have appropriate language as delineated by NAMM California, the Health Plans, CMS and DMHC. 


• Once an appeal is filed, responsible for the coordination and timely submission of a response to the health plan (e.g. clinical documentation, copies of referral requests and denial letters), within the set parameters of NAMM California and the appropriate Health Plan.  These appeals include: appeals generated from denials on acute inpatient stays, pre-authorization requests and SNF level of care issues. Analyzes appeal cases in question for appropriateness of denial through detailed review of records. Issues and follows up on overturn/upheld determination letters.  Works HELD report to maintain timely reporting.


• Responsible for keeping computerized records for submission to UM/QI for quarterly and annual reports, as well as to individual health plans and groups as required. Maintains and organizes all electronic denial files.  Accurately uses database and systems for documentation, tracking and trending.


• Reviews denied authorizations and appeal files for completeness.  Follows up as appropriate for questions, clarification and correction.


• Follows policy and procedures regarding the denial/appeal process.  Orients internal staff to current changes in the denial process. 


• Provides staff relief for Denial Letter and Appeal functions as requested.


• Runs reports for the Unit as requested.


• Assists with QI/Compliance projects as assigned.


• Other duties as may be assigned.

Level of Education

• High School graduate required; AA Degree preferred

Professional Certification or License

• Medical Terminology Certificate preferred

Specific Knowledge, Skills, and Abilities

• 2+ years in health care delivery setting at hospital, clinic, or physician's office or mid level administrative experience.


• Enjoy learning the industry, organizational design and direction and applying technology.  Familiarity with governing entities (CMS, DMHC, and NCQA) is helpful.


• Computer literate in Microsoft products, Crystal reporting, communication software, PC maintenance.  Experience using databases.


• Able to read and interpret information with excellent comprehension and retention.


• Sound decision making, critical thinking and analytical skills


• Excellent written communication skills 


• Excellent interpersonal skills and professional demeanor with clear and concise written communication.


• Strong ability to work effectively with physicians and ancillary staff, both written and verbally.


• Ability to perform complex problem solving related to health care quality.


• Self motivated with strong quantitative and organizational skills.


• Knowledge of general PMG/IPA operations a plus.

Physical Requirements and Work Environment:

• Extended periods of sitting at a computer and use of hands/fingers across keyboard or mouse


• Office environment

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world?s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to doyour life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.