UnitedHealth Group - Worcester, MA
posted 23 days ago
Full-time - Senior
Remote - Worcester, MA
11-50 employees
Insurance Carriers and Related Activities
About the position
The Appeals and Grievances Medical Director is responsible for the clinical review and adjudication of appeals and grievances cases for UnitedHealthcare. This role involves evaluating individual cases related to medical services, ensuring compliance with regulatory standards, and collaborating with medical directors and network management staff to address access and quality issues.
Responsibilities
- Perform individual case review for appeals and grievances for various health plan and insurance products.
- Conduct regulatory responses to the Department of Insurance, Department of Managed Healthcare, and CMS.
- Communicate with UnitedHealthcare medical directors regarding appeals decision rationales and benefit interpretations.
- Engage with regional and plan medical directors and network management staff on access, availability, and quality issues.
- Participate in team meetings focused on communication, feedback, problem solving, and process improvement.
- Provide clinical and strategic input in organizational committees, projects, and task forces.
Requirements
- 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, including typing, word processing, and spreadsheet applications
- Strong team player and team building skills.
Benefits
- Opportunity to work with a Fortune 14 organization
- Commitment to diversity and inclusion
- Drug-free workplace with drug testing policies
