Appeals And Grievances Medical Director
At UnitedHealthcare, 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 systemof tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
Work at home!
The Appeals and Grievances Medical Director is responsible for ongoing clinical review and adjudication of appeals and grievances cases for UnitedHealthcare associated companies.
You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies
- Perform Department of Insurance/Department of Managed Healthcare, and CMS regulatory responses
- Communicate with UnitedHealthcare medical directors regarding appeals decision rationales, and benefit interpretations
- Communicate with UnitedHealthcare Regional and Plan medical directors and network management staff regarding access, availability, network, and quality issues
- Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results
- Provide clinical and strategic input when participating in organizational committees, projects, and task forces
What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- MD or DO with an active, unrestricted license
- Board Certified in an ABMS or AOBMS specialty
- 5+ years clinical practice experience
- 2+ years Quality Management experience
- Intermediate or higher level of proficiency with managed care
- Basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
- Proven excellent telephonic communication skills; excellent interpersonal communication skills
- Proven excellent project management skills
- Proven data analysis and interpretation skills
- Proven excellent presentation skills for both clinical and non-clinical audiences. Familiarity with current medical issues and practices
- Proven creative problem-solving skills
- Proven solid team player and team building skills
Compensation for this specialty generally ranges from $248,500 - $373,000. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
Appeals And Grievances Medical Director
At UnitedHealthcare, 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 systemof tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
Work at home!
The Appeals and Grievances Medical Director is responsible for ongoing clinical review and adjudication of appeals and grievances cases for UnitedHealthcare associated companies.
You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies
- Perform Department of Insurance/Department of Managed Healthcare, and CMS regulatory responses
- Communicate with UnitedHealthcare medical directors regarding appeals decision rationales, and benefit interpretations
- Communicate with UnitedHealthcare Regional and Plan medical directors and network management staff regarding access, availability, network, and quality issues
- Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results
- Provide clinical and strategic input when participating in organizational committees, projects, and task forces
What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- MD or DO with an active, unrestricted license
- Board Certified in an ABMS or AOBMS specialty
- 5+ years clinical practice experience
- 2+ years Quality Management experience
- Intermediate or higher level of proficiency with managed care
- Basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
- Proven excellent telephonic communication skills; excellent interpersonal communication skills
- Proven excellent project management skills
- Proven data analysis and interpretation skills
- Proven excellent presentation skills for both clinical and non-clinical audiences. Familiarity with current medical issues and practices
- Proven creative problem-solving skills
- Proven solid team player and team building skills
Compensation for this specialty generally ranges from $248,500 - $373,000. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
