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This role is responsible for coordination of member navigation plans with Optum clinical and non - clinical staff supporting members in the Navigate4Me program including members referred for CHF, DHN, PSU, HPC, Advanced Illness, ESRD and Transplant. This role will work one - on - one with assigned Optum clinical and non - clinical staff and will support members and their caregivers associated with that assignment in a case management capacity. Members will be warm transferred from Optum clinical and non - clinical staff. Daily responsibilities include warm transfers of members from assigned Optum clinical and non - clinical staff, inbound / outbound calls from / to assigned members and member account research and issue resolution.
- Conduct proactive research on assigned member accounts to identify service issues and inform member plan of navigation in coordination with assigned Optum clinical and / or non - clinical staff outreach. Research includes, but is not limited to:
- Recent contacts
- PCP on account
- Claims Denials
- Mail Order
- Communicate with assigned Optum clinical and / or non-clinical staff regarding member service issues that are proactively identified, member identified and close the loop on the resolution of service issues to inform the plan of navigation for assigned members.
- Resolve member service inquiries related to:
- Medical benefits, eligibility and claims
- Terminology and plan design
- Financial spending accounts
- Pharmacy benefits, eligibility and claims
- Correspondence requests
- Educate members about the fundamentals of health care benefits including:
- Managing health and well being
- Maximizing the value of their health plan benefits
- Selecting the best health plan to meet their health needs
- Choosing a quality care provider and appointment scheduling
- Premium provider education and steerage
- Pre - authorization and pre - determination requests and status
- Own problem through to resolution on behalf of the member in real time or through comprehensive and timely follow - up with the member
- Communicate with members and their care givers regarding anticipated member service needs and resolution of issues
- Research complex issues across multiple databases and work with support resources to own the resolution of all customer issues and anticipate their future healthcare needs or potential opportunities to improve the experience
- Interact with executives and senior leaders to identify and / or resolve member issues including ongoing communication of issue outcome
- Build and maintain an elaborate list of business partners across all lines of business to escalate member inquiries on an as needed basis
- Employees may be asked to work independently after hours to resolve urgent issues that surface after normal business hours. This role has the ability to work outside of established procedures to ensure high level member satisfaction
- Identify gaps in processes and work closely with other departments for process improvement
- Provide education and status on previously submitted pre - authorizations or pre - determination requests
- Meet the performance goals established for the position in the areas of: efficiency, call quality, customer satisfaction, first call resolution and attendance
- Maximize use of community services, support programs, and resources available to member
- San Antonio, TX, Irving, TX, Colorado Springs, CO, Roanoke, VA, St Louis, MO, Harlingen, TX or US Telecommute
- High School Diploma / GED or higher
- 1+ years of experience within an Advocate Role supporting one or more of the following products: MA West, MA East, Group, PDP, Outbound
- Successful completion of new hire training and demonstrated proficiency in Benefits Advocate role
- Experience in Health Care / Insurance environment (familiarity with medical terminology, health plan documents, or benefit plan design)
- Ability to work between 7:00 am - 7:00 pm
- 2+ years of experience in a Customer Service environment
The Boomer generation is the fastest growing market segment in healthcare. And we are the largest business in the nation dedicated to serving their unique health and well - being needs. Up for the challenge of a lifetime? Join a team of the best and the brightest to find bold new ways to proactively improve the health and quality of life of these 9 million customers. You'll find a wealth of dynamic opportunities to grow and develop as we work together to heal and strengthen our Healthcare system. Ready? It's time to do your life s best work.
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.
Keywords: MA West, MA East, Group, PDP, Outbound, customer service