Role Description The Clinical Preservice/Clinical Appeals Reviewer is responsible for performing MassHealth LTSS pre-service clinical coverage reviews and determinations and clinically appropriate appeal hearing representation. The Preservice Reviewer/ Clinical Appeals is responsible for attending appeal hearings, defending MassHealth LTSS prior authorization determinations. This position collaborates closely with managers and peers. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Assesses the appropriateness of services when adjudicating prior authorizations based on submitted documentation, benefit plan, MassHealth policies and medical necessity guidelines, program requirements, and standards of care. - Identifies solutions to non-standard requests and problems. - Participates in regular meetings with leadership and team members to support collaboration and ensure operational efficiency and team alignment. - Maintains performance in accordance with established quality standards, evidence-based guidelines, departmental benchmarks, and operational workflows. - Adjudicates prior authorizations in a timely manner, ensuring completion ahead of Cornelius due dates to ensure compliance with the Interoperability Rule. - Promotes consistency and accuracy in clinical decision-making by applying medical necessity guidelines and program standards across cases and programs. - Engages, coordinates, and provides education to LTSS providers on prior authorization requirements and medical necessity guidelines to support clinical decision making. - Provides clinical mentorship and guidance to support junior reviewer development. - Acts as an SME for specific service lines or programs, providing specialized expertise. - Supports cross-functional programs and workstream initiatives. - Adheres to their approved assigned schedule and participates in overtime coverage as required by program needs. - Responds to and assists with support of inquiries and escalations. - Effectively manages and prioritizes workload to meet quality and productivity goals. - Performs additional duties and provides coverage assigned by management. Clinical & Regulatory Responsibilities - Maintains compliance with MassHealth clinical guidelines, regulatory requirements (CMS and applicable state and federal regulations), and program policies. - Works with internal stakeholders (e.g., Medical Directors, Team Leads, Program Managers) to support the clinical coverage review process and elevates complex or high-risk cases to clinical leadership. - Identifies and reports on utilization trends, including potential overuse or underuse of services. - Supports audit, regulatory, and accreditation activities to maintain compliance and program integrity. - Prepares and presents cases for discussion during weekly clinical case rounds. Appeals Responsibilities - Ensures the appeals process is executed in compliance with regulatory and business unit standards, including scheduling appeals for designated PA appeals staff. - Acts as a liaison between the OLTSS and the BOH, fostering collaboration and effective communication. - Attends BOH proceedings for high-profile or complex appeal cases as needed. - Coordinates appeals activities with the applicable LTSS Program Manager. - Provides support for prehearing conferences through planning and collaboration. - Oversees quality assurance for the Appeals team, ensuring consistency and adherence to standards. - Analyzes trends within appeals and recommends policy enhancements in response to identified patterns impacting PA appeals. Documentation & Quality Assurance - Maintains clear, accurate, and defensible documentation in all prior authorization determinations and corresponding decision letters in accordance with MassHealth guidelines as well as state regulations and federal regulations. - Participates in internal and external quality audits as needed. - Drives improvement in individual quality performance and productivity metrics through ongoing monitoring and analysis. - Ensures prior authorizations are adjudicated ahead of the Cornelius due date to remain in compliance with the CMS Interoperability Rule. - Maintains a PA audit score of at least 90%. - Demonstrates proficiency by earning a minimum score of 75% on the IRR Assessment. - Performs all assigned duties in compliance with SLA and contractual requirements. Communication & Provider Collaboration - Communicates determinations clearly and professionally. - Engages in provider outreach as needed to support prior authorization determinations. - Educates providers on prior authorization and medical necessity criteria. - Collaborates with PAUM programs and MALTSS workstreams to support program objectives as appropriate. Operational Efficiency & Process Improvement - Identifies workflow inefficiencies and recommends process improvements. - Participates in process improvement projects, including automation or system enhancements. - Supports onboarding and training of new staff as needed. - Demonstrates proficiency in clinical systems and documentation tools. - Independently resolves moderately complex issues with minimal supervision. Professional Development - Maintains current clinical knowledge through ongoing continuing education, training, and professional development. - Keeps up to date with program requirements, regulatory changes, and evolving clinical guidelines. - Stays informed on industry best practices and internal organizational processes. - Monitors updates to MassHealth policies, clinical guidelines, and authorization requirements to ensure compliance. - Participates in competency assessments and completes all required ongoing training. Qualifications - Ability to maintain current professional licensure in accordance with contractual requirements, ensuring alignment with the qualifications necessary to effectively perform assigned job duties. - Demonstrated solid written and verbal communication skills, with the ability to build relationships and collaborate effectively. - Ability to work independently and as part of a team. Requirements - *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (all benefits are subject to eligibility requirements). - Hourly pay for this role will range from $35.00 to $63.00 per hour based on full-time employment.

• Conduct orientation to medical records for new abstraction team members • Manage the green-lighting process and completion of on-going IRR, identifying any performance concerns in collaboration with the Clinical Services Lead and escalating concerns to Senior Manager/Manager • Effectively manage the fallout review/exception/occurrence reporting and Second Look process, ensuring accurate reporting, and partnering with the Clinical Services Lead to ensure partner notification and review • Provide follow-up/feedback/education to the project team on quality issues or trends identified during greenlighting, on-going IRR, second looks, pre-submission cleaning, review of project quality trends, etc. • Collaborate with Clinical Services Lead and Senior Manager/Manager to identify quality trends in the data with respect to internal team performance, and also identify hospital quality trends to share with partners • Mentor, train and provide guidance to new hires during the onboarding process at assigned facilities • Maintain and share abstraction team support documents, including Measure Detail and Documentation Clarification Forms, regularly updating with new measures and/or partner EMR changes • Complete the 1st pass of pre-submission clean-up, update cases when missing documentation is provided • Subject matter expert in assigned registry or measure. Provide expert abstraction support – 15% - 20% abstraction • Other quality tasks, as assigned • Attend new partner orientation in order to orient new team members as added to the project • Work closely with the Clinical Services Lead, as needed, for case-specific questions • Other partner tasks, as delegated by the Clinical Services Lead or the Senior Manager/Manager

Role Description The Clinical and Coding Quality Supervisor provides direct operational leadership and subject matter oversight for all daily clinical and coding quality workflows and assignments. This role is responsible for ensuring the accuracy, consistency, and effectiveness of second-level coding quality review workflows that support: - Risk adjustment - DRG integrity - Regulatory compliance - Institutional quality and financial performance Promote and support teamwork and engagement, performance excellence, accountability, and professionalism. Lead and support process improvement. Ensure the Clinical & Coding Quality Team have the education and tools they need to successfully perform to the highest levels of quality and compliance. Qualifications - Associate's Degree in nursing or health information management - 5 years of experience working in an Acute Hospital setting, preferably in an Academic environment - 3 to 5 years of experience working in a Quality/Risk Program - Experience utilizing methodology-specific risk calculators and guidance documents - Experience working in a remote environment - Licenses and Certifications: - Registered Health Information Management (RHIA) - Registered Nurse (RN) with Certified Clinical Documentation Specialist (CCDS) - Registered Health Information Technology (RHIT) - AHIMA Certified Coding Specialist (CCS) - Preferred: Bachelor's Degree in nursing or health information management Requirements - Manage staffing and all employee-related duties - Provide day-to-day supervision of Coding Quality Analysts, including work assignment, prioritization, performance monitoring, and issue resolution - Oversee all quality workflow and assignments - Ensure quality changes are completed within revenue cycle goals and corrections are completed within deadlines - Serve as the primary escalation point for complex CDI, coding, DRG, and risk-adjustment questions requiring advanced review - Oversee coding quality audits validating ICD-10-CM/PCS code assignment accuracy - Track, trend, and report quality metrics, including error rates, rework, and risk-adjustment performance - Identify front-end workflow issues impacting coding quality and recommend process improvements - Collaborate with Denials Team processes and initiatives - Maintain an expert level of knowledge of Coding, CDI, Denials, and Appeal guidelines and practices - Onboard, train, and audit all direct reports - Support the Quality Standards set by UTSW & the Coding Quality & Integrity Department - Other duties as assigned Benefits - PPO medical plan, available day one at no cost for full-time employee-only coverage - 100% coverage for preventive healthcare - no copay - Paid Time Off, available day one - Retirement Programs through the Teacher Retirement System of Texas (TRS) - Paid Parental Leave Benefit - Wellness programs - Tuition Reimbursement - Public Service Loan Forgiveness (PSLF) Qualified Employer

Description and Requirements The Team You Will Join On MetLife's Global Customer Service and Operations (GCSO) team, customer care is built on trust, empathy, and a commitment to continuous improvement. Whether guiding customers through life's important moments, solving challenges, or simplifying processes with innovative technology, you'll help deliver a differentiated experience grounded in operational excellence. Backed by a collaborative team, you'll play a vital role in strengthening the way we care and advocate for millions worldwide. Here, making a real difference isn't just a goal - it's what we do, one conversation at a time. The Opportunity The Claim Reviewer is responsible for providing high quality review and payment of claims, and also provide compassionate service to our beneficiaries and families of deceased employees to assist with the claims process across the country . This is an exciting opportunity to learn the Group Life claims process and potential to further your development, while making a positive impact on our claimants. Key Responsibilities - Checks Group Life claim documentation or other company forms for completeness and accuracy. - Evaluate Group Life claim submissions for accuracy to ensure correct claim payment. - Evaluate Group Life claim submissions to identify situations requiring referral to Claim Examiner. - Reviews data from various sources, including policyholders; translates it into appropriate media for input into a Windows based computer system (BIOS). - Respond to written and/or telephone inquiries from policyholders, beneficiaries, attorneys and families of deceased employees. - Provide guidance to beneficiaries on claim processes and resolve customer issues swiftly and thoroughly. - Completes all work within turnaround time to meet department and customer objectives. - Maintain production and quality standards. - Ensure compliance with state regulations for Group life claims by sending appropriate notifications. - Perform support functions as needed. - Provide high quality, timely service to policyholders, beneficiaries, attorneys, families of deceased employees and administration; resolve customer issues swiftly and thoroughly by offering recommendations and solutions. - Mentor Reviewers as needed - Provide compassionate call outs to claimants to assist with the claims process and offer additional services. Required Qualifications - New hires should live a commutable distance from Oriskany NY. - Strong communication skills, both written and oral. - Demonstrated critical thinking in activities requiring analysis, investigation, and/or planning. - Experience with Microsoft Suite (Word, Excel, Teams, etc.) - 1+ years Customer Service background with a focus on delivering white glove service to clientele. - High School Diploma or GED equivalent. - This role has mandatory paid training starting on September 8. Candidates must be available and present for all training days. Preferred Qualifications - 1+ years' experience in a call center. Focus on outbound calls preferrable. - Prior experience reviewing insurance claims. - Background in Life Claims (Claim intake and Notice of Loss). - College Degree or high education. The expected salary range for this position is $41,600 - $54,000 . This role may also be eligible for annual short-term incentive compensation and stock-based long-term incentives. All incentives and benefits are subject to the applicable plan terms. Benefits We Offer Our U.S. benefits address holistic well-being with programs for physical and mental health, financial wellness, and support for families. We offer a comprehensive health plan that includes medical/prescription drug and vision, dental insurance, and no-cost short- and long-term disability. We also provide company-paid life insurance and legal services, a retirement pension funded entirely by MetLife and 401(k) with employer matching, group discounts on voluntary insurance products including auto and home, pet, critical illness, hospital indemnity, and accident insurance, as well as Employee Assistance Program (EAP) and digital mental health programs, parental leave, paid time off, paid holidays, volunteer time off, tuition assistance and much more! About MetLife Recognized on Fortune magazine's list of the "World's Most Admired Companies", Fortune World's 25 Best Workplaces™, as well as the Fortune 100 Best Companies to Work For®, MetLife, through its subsidiaries and affiliates, is one of the world's leading financial services companies; providing insurance, annuities, employee benefits and asset management to individual and institutional customers. With operations in more than 40 markets, we hold leading positions in the United States, Latin America, Asia, Europe, and the Middle East. Our purpose is simple - to help our colleagues, customers, communities, and the world at large create a more confident future. United by purpose and guided by our core values - Win Together, Do the Right Thing, Deliver Impact Over Activity, and Think Ahead - we're inspired to transform the next century in financial services. At MetLife, it's #AllTogetherPossible . Join us! MetLife is an Equal Opportunity Employer. All employment decisions are made without regards to race, color, national origin, religion, creed, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, marital or domestic/civil partnership status, genetic information, citizenship status (although applicants and employees must be legally authorized to work in the United States), uniformed service member or veteran status, or any other characteristic protected by applicable federal, state, or local law ("protected characteristics"). If you need an accommodation due to a disability, please email us at accommodations@metlife.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process. MetLife maintains a drug-free workplace. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liabilities.