Appeals Medical Director - Remote

UnitedHealthcare; Cypress (CA); Remote; USD 249,000 - 373,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

UnitedHealthcare is seeking an Appeals and Grievances Medical Director to lead clinical review and adjudication of appeals and grievances across multiple health plans. The role requires an MD/DO with a current license and board certification, backed by at least five years of clinical practice and two years in Quality Management.

The position is remote with collaboration across medical directors, regulatory bodies, and network management.

Qualifications

• MD or DO with an active, unrestricted license.
• Board Certified in an ABMS or AOBMS specialty.
• 5+ years clinical practice experience.
• 2+ years of Quality Management experience.
• Proficiency with managed care.
• Proven telephonic and interpersonal communication skills.
• Proven project management and data analysis skills.
• Proven presentation skills for clinical and non-clinical audiences.
• Proven solid team player and problem-solving skills.

Responsibilities

• Perform individual case review for appeals and grievances across health plans and products.
• Handle regulatory responses (DOI/DMHC/CMS).
• Communicate with medical directors on rationales and benefit interpretations.
• Coordinate with regional and plan medical directors and network staff on access, network and quality issues.
• Participate in team meetings focused on communication, feedback, problem solving, and process improvement.
• Provide clinical and strategic input in organizational committees and projects.

Skills

MD/DO license

Board Certified

Quality Management

Managed care proficiency

Telephonic communication

Project management

Data analysis

Presentation skills

Team player

Adaptability

Education

MD/DO degree

Tools

MS Office

Internet research

Job description

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 in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together.

Work at home!

The Appeals and Grievances Medical Director is responsible for ongoing clinical review and adjudication of appeals and grievances cases for UnitedHealthcare associated companies.

Primary 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

Required Qualifications

• MD or DO with an active, unrestricted license
• Board Certified in an ABMS or AOBMS specialty
• 5+ years clinical practice experience
• 2+ years of Quality Management experience
• Intermediate or higher level of proficiency with managed care
• Basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
• 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. Familiarity with current medical issues and practices
• Proven creative problem-solving skills
• Proven solid team player and team building skills

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $248,500 - $373,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.