Appeals M.D. - Emergency Meds - Required - Remote

UnitedHealth Group Inc.•Cypress, CA

56d•$238,000 - $357,500•Remote

About The Position

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 system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. The Appeals and Grievances Medical Director is responsible for ongoing clinical review and adjudication of appeals and grievances cases for UnitedHealthcare associated companies. Performance accountabilities include: 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.

Requirements

MD or DO with an active, unrestricted license
Board Certified in an ABMS or AOBMS specialty
5+ years of clinical practice experience
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Nice To Haves

2+ years of Quality Management experience
Intermediate or higher level of proficiency with managed care
Excellent telephonic communication skills; excellent interpersonal communication skills
Excellent project management skills
Data analysis and interpretation skills
Excellent presentation skills for both clinical and non-clinical audiences. Familiarity with current medical issues and practices
Creative problem-solving skills
Basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
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