Appeals and Grievances Medical Director - Virtual(Job Number:702968)
Work at home!
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 healthplan 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.
Job Clinical Analysis & Consulting
Primary Location US-California
Other Location US-TX-Dallas, US-NY-New York, US-FL-Tampa, US-AZ-Phoenix, US-IL-Chicago, US-CA-Los Angeles
Organization Clinical Appeals & Grievances
Number of Openings 1