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Appeals and Grievances --- Work From Home 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.
Qualifications: -MD or DO with an active, unrestricted license -Board Certified in an ABMS or AOBMS specialty -5+ years clinical practice experience -Intermediate or higher level of proficiency with managed care -2+ years Quality Management experience - 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 - Strong team player and team building skills.
Careers with UnitedHealthcare: Let's talk about opportunity. Start with a Fortune 14 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.SM
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing. Associated topics: care, care physician, family medicine, family medicine physician, family practice physician, outpatient, physician, practice physician, provider, urgent
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.