Remote Pediatric Appeals & Grievances Medical Director

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

Job summary

UnitedHealthcare is seeking an Appeals and Grievances Medical Director to oversee clinical review and adjudication of appeals across multiple health plans. The role supports remote work from anywhere in the United States and involves regulatory responses, cross-functional collaboration, and strategic input on committees and projects.

Candidates must hold an MD or DO with a valid license, board certification, and 5+ years of clinical practice with 2+ years in Quality Management.

Qualifications

• MD or DO with an active, unrestricted license.
• Board certification 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.
• Proven 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.

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.

Skills

MD or DO license

ABMS/AOBMS board certification

Clinical practice experience

Quality management experience

Managed care proficiency

Computer skills (typing, MS Office)

Telephonic communication

Project management

Data analysis & interpretation

Presentation skills

Teamwork

Medical knowledge of current issues

Job description

UnitedHealthcare is seeking an Appeals and Grievances Medical Director to oversee clinical review and adjudication of appeals across multiple health plans. The role supports remote work from anywhere in the United States and involves regulatory responses, cross-functional collaboration, and strategic input on committees and projects.

Candidates must hold an MD or DO with a valid license, board certification, and 5+ years of clinical practice with 2+ years in Quality Management.