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Appeals and Grievances Medical Director - Cardiologist - Virtual - 2178789

Optum

Optum

Chicago, IL, USA · Boston, MA, USA · Houston, TX, USA
Posted on Thursday, August 24, 2023

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join 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 work remotely * 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.

 

What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you’ll open doors for yourself that simply do not exist in any other organization, anywhere.

    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

    Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That’s why you’ll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life’s best work.(sm) 

     

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

      

    California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington residents is  $248,582 to $338,965 . 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.

      

    At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.    

     

      

    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.