[Hiring] Appeals M.D. - Pediatrician @UnitedHealth Group

Role Description

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

You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

• Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP.
• Respond 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 - No Pediatrics.
• 5+ years of clinical practice experience.

Requirements

• 2+ years of Quality Management experience.
• Intermediate or higher level of proficiency with managed care.
• 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 basic computer skills, typing, word processing, presentation, and spreadsheet applications skills.
• Internet researching skills.
• Proven solid team player and team building skills.

Benefits

• Compensation generally ranges from $248,500 - $373,000.
• Total cash compensation includes base pay and bonus based on several factors including local labor markets, education, work experience, and may increase over time based on productivity and performance in the role.
• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).