Senior Medical Director - Appeals and Grievances - Virtual(Job Number:706649)
The Senior Appeals and Grievances Medical Director is responsible for the ongoing management of the clinical appeals and grievances processes relating to the medical directors services within the UnitedHealthcare Clinical Services organization, their work processes, and the quality and quantity performance of their work.. This team of medical directors would provide a consistent approach to the management of clinical appeals to improve member/provider experience, meet client expectations, and to better meet federal and state regulatory requirements. This medical director will also have specific responsibilities for doing clinical review and adjudication of appeals and grievances cases for UnitedHealthcare associated companies. Performance accountabilities include:
- Develop policies and procedures, and standard operating procedures that will provide a consistent approach to clinical appeal medical director adjudication processes for the clinical appeal departments across all three business segments.
- Directly manage appeal and grievances medical directors in his/her reporting structure.
- Interface with senior management across the three business segments.
- Maintain federal and state regulatory compliance for clinical appeals.
- Oversee escalated issues regarding specific appeal and grievances cases adjudications related to risk management and/or compliance issues.
- Participate in various audits for accreditation, compliance, and quality management.
- 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.
- Preparation and management of legal and risk cases with the potential for written responses, testimony in depositions and various forms of legal hearings.
- Peer to peer communications in investigating appeals and grievances related issues.
- Communicate feedback with UnitedHealthcare medical directors regarding appeals decision rationales, and benefit interpretations.
- 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.
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
Organization Clinical Appeals & Grievances
Number of Openings 1