Appeals MD - Family or Internal Medicine Required - Remote

UnitedHealth Group•Sylacauga, AL

1d•$248,500 - $373,000•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 role reviews cases involving various health plan and insurance products, including PPO, ASO, HMO, MAPD, and PDP, and appeals of adverse determinations related to medical services, benefit design, coverage, and application of clinical criteria and medical policies. This remote position is available to candidates working from anywhere within the United States. The Medical Director also handles regulatory responses, communicates with medical directors and operational staff about appeal rationales, benefit interpretations, access, network, availability, and quality issues, and participates in team meetings and organizational committees, projects, and task forces. The position provides clinical and strategic input and contributes to problem solving, process improvement, staff training and 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 and use of word processing, presentation, and spreadsheet applications, as well as internet research skills.
Excellent telephonic and interpersonal communication skills.
Excellent project management skills.
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

Perform individual case reviews for appeals and grievances across various health plan and insurance products, including PPO, ASO, HMO, MAPD, and PDP.
Review appeals concerning adverse determinations for medical services, benefit design and coverage, and application of clinical criteria and medical policies.
Provide 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 in organizational committees, projects, and task forces.