Appeals Medical Director - General Medicine Required - Remote

UnitedHealth Group•Cypress, CA

1d•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 Work at home! You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week. 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 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
2+ years of Quality Management experience
Familiarity with current medical issues and practices
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
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
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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