Appeals M.D. - Pediatrician - Remote

UnitedHealth Group•Tampa, FL

13h•$248,500 - $373,000•Remote

About The Position

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. This role involves performing 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. The role also includes performing Department of Insurance/Department of Managed Healthcare, and CMS regulatory responses, communicating with UnitedHealthcare medical directors regarding appeals decision rationales, and benefit interpretations, and communicating with UnitedHealthcare Regional and Plan medical directors and network management staff regarding access, availability, network, and quality issues. You will actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results. Additionally, you will provide clinical and strategic input when participating in organizational committees, projects, and task forces.

Requirements

MD or DO with an active, unrestricted license
Board Certified in an ABMS or AOBMS specialty - No Pediatrics
5+ years of clinical practice experience
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
Candidates are required to pass a drug test before beginning employment.

Nice To Haves

2+ years of Quality Management experience
Intermediate or higher level of proficiency with managed care
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 basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
Proven solid team player and team building skills

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