Appeals Medical Director - Remote
About The Position
The Appeals and Grievances Medical Director conducts ongoing clinical review and adjudication of appeals and grievances for UnitedHealthcare-associated companies. The role reviews appeals across health plan and insurance products, including PPO, ASO, HMO, MAPD, and PDP, addressing adverse determinations related to medical services, benefit design and coverage, and the application of clinical criteria in medical policies. The position also handles regulatory responses and communicates with medical directors and other staff about appeal rationales, benefit interpretations, access, availability, network, and quality issues. This remote role includes active participation in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and sharing program results. The Medical Director also provides clinical and strategic input to organizational committees, projects, and task forces. The position offers development opportunities and a comprehensive benefits package, subject to eligibility requirements.
Requirements
- MD or DO with an active, unrestricted license.
- Board certified 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; 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.
- Solid team player and team-building skills.
Responsibilities
- Review individual appeals and grievances cases for various health plan and insurance products, potentially including PPO, ASO, HMO, MAPD, and PDP.
- Review appeals concerning 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 appeal decision rationales and benefit interpretations to UnitedHealthcare medical directors.
- Communicate with UnitedHealthcare 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.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase program.
- 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
