Appeals and Grievances Medical Director - Medicare Appeals - Virtual

Company: Optum
Location: Cypress
Posted on: May 3, 2022

Job Description:

Medical Director opening in Cypress, California. This and other physician jobs brought to you by DocCafe.com

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)



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 telecommute* from anywhere within the U.S. as you take on some tough challenges.



Primary 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
  
  
  
  
  You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
  Required Qualifications:
  
  
  • 
    
  • MD or DO with an active, unrestricted license
    
  • Board Certified in an ABMS or AOBMS specialty
    
  • 5+ years clinical practice experience
    
  • 2+ years Quality Management experience
    
  • Intermediate or higher level of proficiency with managed care
    
    
    
    
    Preferred Qualifications:
    
    
    • 
      
    • Excellent telephonic communication skills
      
    • Excellent interpersonal communication skills
      
    • Excellent project management skills
      
    • Data analysis and interpretation skills
      
    • Excellent presentation skills for both clinical and non-clinical audiences. Familiarity with current medical issues and practices
      
    • Creative problem-solving skills
      
    • Basic computer skills, typing, word processing, presentation, and spreadsheet applications skills
      
    • Internet researching skills
      
    • Solid team player and team building skills
      
      
      
      
      UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.
      
      
      
      Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)
      
      
      
      *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
      
      
      
      Colorado, Connecticut or Nevada Residents Only: The Salary range for Colorado, Connecticut and Nevada residents is $254,600 to $295,200. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives
      
      
      
      
      
      Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
      
      
      
      UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
      
      
      
      
      
      Job Keywords: Appeals and Grievances Medical Director, Medicare Appeals, Virtual, Telecommute, Telecommuter, Telecommuting, Work at Home, Work from Home, Remote
      
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