Senior Medical Director - Appeals and Grievances - Virtual

• 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 Qualifications:
• Excellent telephonic communication skills; excellent interpersonal communication skills.
• Strong knowledge of managed care industry.
• 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.
• Unrestricted medical licensed physician; Board Certified in a medical or surgical specialty/subspecialty
• 10 years clinical practice experience.
• Supervisory skills including clinical mentoring and coaching skills.

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 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

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.