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Appeals & Grievances Medical Director - Virtual

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Company: UnitedHealth Group

Location: Los Angeles, CA

Date Posted: July 5, 2014

Source: UnitedHealth Group

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 ...

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.

Requirements

Qualification:

-MD or DO with an active, unrestricted license
-Board Certified in an ABMS or AOBMS specialty
-5+ years clinical practice experience

-Intermediate or higher level of proficiency with managed care
-2+ years Quality Management experience

- 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.
- Strong team player and team building skills.

UnitedHealthcare, part of the UnitedHealth Group family of companies, is comprised of three specialized businesses dedicated to meeting the health care benefits needs of individuals and groups; all part of something greater, but each with a specialized focus:

UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.

UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.

UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.

Together, we�re removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being.

Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives.

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

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