Appeals M.D. - FM or ER Required - Remote
About The Position
The Appeals and Grievances Medical Director conducts ongoing clinical review and adjudication of appeals and grievances for UnitedHealthcare associated companies. Reviews address adverse determinations for medical services related to benefit design and coverage, and the application of clinical criteria in medical policies. Cases may involve PPO, ASO, HMO, MAPD, and PDP products. The role also handles regulatory responses and communicates with medical directors and other UnitedHealthcare teams about decisions, benefits, access, networks, and quality issues. This remote position is open to candidates located anywhere within the United States. The Medical Director contributes to team meetings, organizational committees, projects, and task forces, with a focus on communication, problem solving, process improvement, training, evaluation, and sharing program results.
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, plus internet research skills.
- Excellent telephonic and interpersonal communication skills.
- Excellent project management skills.
- Data analysis and interpretation skills.
- 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 individual appeals and grievances cases for various health plan and insurance products, including PPO, ASO, HMO, MAPD, and PDP.
- Conduct clinical reviews of appeals related to adverse determinations, benefit design and coverage, and application of clinical criteria in 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 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.
- Equity stock purchase plan.
- 401(k) contribution.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Ph.D. or professional degree
