Medical Director, Appeals & Grievances — Remote

Oncology Voice Network LLC; Cypress, Northern (CA, KY); Hybrid; USD 249,000 - 373,000; Full time

Job summary

UnitedHealth Group's UnitedHealthcare division seeks an Appeals and Grievances Medical Director to lead clinical review and adjudication for appeals across PPO, HMO, MAPD and PDP plans. This remote-friendly role supports health plan operations nationwide.

Requirements include MD or DO with an active license, ABMS/AOBMS board certification, 5+ years of clinical practice, 2+ years in quality management, and strong communication, project management, data analysis and presentation skills.

Qualifications

• 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.
• Excellent telephonic communication skills; excellent interpersonal communication skills.
• Proven project management skills.
• Proven data analysis and interpretation skills.
• Proven excellent presentation skills for both clinical and non-clinical audiences.
• Creative problem-solving skills.
• Basic computer skills, typing, word processing, presentation, and spreadsheet applications.
• 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.
• 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

Skills

Telephonic communication

Interpersonal communication

Project management

Data analysis

Presentation skills

Teamwork

Problem-solving

Education

MD or DO degree

Active medical license

Board Certification (ABMS/AOBMS)

Tools

Microsoft Office

Job description

UnitedHealth Group's UnitedHealthcare division seeks an Appeals and Grievances Medical Director to lead clinical review and adjudication for appeals across PPO, HMO, MAPD and PDP plans. This remote-friendly role supports health plan operations nationwide.

Requirements include MD or DO with an active license, ABMS/AOBMS board certification, 5+ years of clinical practice, 2+ years in quality management, and strong communication, project management, data analysis and presentation skills.