[Hiring] Appeals M.D. Pulmonologist/Pulmonary Allergy @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. Performance accountabilities include:

• 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.

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.
• 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.
• 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.

Requirements

• *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).
• Salary range: $248,500 - $373,000 annually based on full-time employment.