Remote Medical Director — Appeals & Grievances

ISHE; Cypress (CA); Hybrid; USD 238,000 - 358,000; Full time

Benefits offered by this job

Comprehensive benefits

Equity stock purchase

401k contribution

Job summary

UnitedHealth Group is seeking a Medical Director for Appeals and Grievances to lead clinical review and adjudication for UnitedHealthcare associated companies. This remote role offers the flexibility to work from home across the United States while delivering high-quality decisions on complex cases and improving patient care.

Responsibilities include performing case reviews for appeals and grievances across PPO, HMO, MAPD and PDP products; addressing regulatory requests from DOI/DMHC and CMS;

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 and data analysis.
• Excellent telephonic and interpersonal communication skills.
• Strong project management and presentation skills.
• Solid team player and team-building abilities.

Responsibilities

• Perform individual case review for appeals and grievances across plans (PPO, ASO, HMO, MAPD, PDP).
• Handle regulatory responses from DOI/DMHC and CMS.
• Communicate rationale to medical directors and network staff.
• Collaborate with regional and plan medical directors and network management on access and quality issues.
• Participate in team meetings and process-improvement initiatives.
• Provide clinical and strategic input on committees and projects.

Skills

MD/DO license

Board Certified

Clinical practice

Quality Management

Managed care proficiency

Data analysis

Presentation skills

Project management

Team player

Telecommuting capability

Education

MD or DO degree

Tools

Microsoft Office

Job description

UnitedHealth Group is seeking a Medical Director for Appeals and Grievances to lead clinical review and adjudication for UnitedHealthcare associated companies. This remote role offers the flexibility to work from home across the United States while delivering high-quality decisions on complex cases and improving patient care.

Responsibilities include performing case reviews for appeals and grievances across PPO, HMO, MAPD and PDP products; addressing regulatory requests from DOI/DMHC and CMS;