Appeals M.D. – Pediatrician Required - Remote
About The Position
The Appeals and Grievances Medical Director performs ongoing clinical review and adjudication of appeals and grievances for UnitedHealthcare associated companies. The position conducts individual case reviews across various health plan and insurance products, including PPO, ASO, HMO, MAPD, and PDP, addressing appeals of adverse determinations related to medical services, benefit design and coverage, and the application of clinical criteria and medical policies. The role also handles regulatory responses and communicates with medical directors and other colleagues about appeal rationales, benefit interpretations, access, availability, network, and quality issues. This remote position may be performed from anywhere within the United States. The Medical Director contributes to team meetings and organizational committees, projects, and task forces, supporting communication, problem solving, process improvement, staff training and evaluation, and the sharing of program results. The role provides clinical and strategic input and offers a comprehensive benefits package, incentive and recognition programs, an equity stock purchase program, and a 401(k) contribution, subject to eligibility requirements.
Requirements
- MD or DO with an active, unrestricted license.
- Board certification in an ABMS or AOBMS specialty.
- At least 5 years of clinical practice experience.
- At least 2 years of Quality Management experience.
- Intermediate or higher proficiency with managed care.
- Basic computer skills, including typing, word processing, presentation, and spreadsheet applications, as well as internet research skills.
- Proven telephonic communication skills and excellent interpersonal communication skills.
- Proven project management skills.
- Proven data analysis and interpretation skills.
- Excellent presentation skills for clinical and non-clinical audiences.
- Familiarity with current medical issues and practices.
- Creative problem-solving skills.
- Ability to be a solid team player and contribute to team building.
Responsibilities
- Review and adjudicate individual appeals and grievances for various health plan and insurance products, including PPO, ASO, HMO, MAPD, and PDP.
- Review appeals involving adverse determinations for medical services, benefit design and coverage, and the application of clinical criteria and medical policies.
- Prepare responses to Department of Insurance, Department of Managed Healthcare, and CMS regulatory matters.
- Communicate appeal decision rationales and benefit interpretations to UnitedHealthcare medical directors.
- Communicate with UnitedHealthcare Regional and Plan medical directors and network management staff regarding access, availability, network, and quality issues.
- Participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and sharing program results.
- Provide clinical and strategic input to organizational committees, projects, and task forces.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs, subject to eligibility requirements.
- Equity stock purchase program, subject to eligibility requirements.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Ph.D. or professional degree
