Logo of Huzzle

Appeals and Grievances Medical Director - Pulmonology - Remote

  • Job
    Full-time
    Senior Level
  • Government & Politics
    Healthcare
  • Cypress
    Remote

AI generated summary

  • You must be an MD or DO, board-certified in Pulmonology, with 5+ years of clinical and 2+ years in Quality Management experience, strong communication, project management, and data analysis skills.
  • You will review appeals and grievances, respond to regulatory inquiries, collaborate with medical directors, address network issues, participate in team meetings, and provide clinical input on projects.

Requirements

  • MD or DO with an active, unrestricted license
  • Pulmonology Board Certified in an ABMS or AOBMS specialty
  • 5+ years of clinical practice experience
  • 2+ years Quality Management experience
  • Intermediate or higher level of proficiency with managed care
  • Proven excellent telephonic communication skills; excellent interpersonal communication skills
  • Proven excellent project management skills
  • Proven data analysis and interpretation skills
  • Proven excellent presentation skills for both clinical and non-clinical audiences. Familiarity with current medical issues and practices
  • Proven creative problem-solving skills
  • Proven basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
  • Proven solid team player and team building skills
  • All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Responsibilities

  • 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
  • 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

FAQs

Do we support remote work?

Yes, this position is fully remote and you can work from anywhere within the U.S.

What qualifications are required for the Appeals and Grievances Medical Director position?

The required qualifications include an MD or DO with an active, unrestricted license, Pulmonology Board Certification, 5+ years of clinical practice experience, and 2+ years of Quality Management experience, among other skills.

What type of experience is preferred for this role?

Preferred experience includes 5+ years in clinical practice, 2+ years in Quality Management, proficiency in managed care, and proven project management and data analysis skills.

Is there a salary range for this position?

Yes, the salary range for this role is between $269,500 to $425,500 annually, based on various factors such as experience and metric achievement.

Are there benefits associated with this position?

Yes, UnitedHealth Group offers a comprehensive benefits package including incentive and recognition programs, equity stock purchase, and 401k contributions, all subject to eligibility requirements.

What is the application deadline for this job posting?

The application will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected, which may result in an early closure due to a high volume of applicants.

What type of work environment can I expect at UnitedHealth Group?

You can expect a collaborative team culture focused on clinical and business cooperation, which is designed to foster learning and development within a challenging yet rewarding environment.

How does UnitedHealth Group approach diversity and inclusion?

UnitedHealth Group is committed to creating a diverse workplace and promotes equity in healthcare services, ensuring all individuals, regardless of their background, have the opportunity to live their healthiest life.

Will I need to travel for this role?

This position is primarily remote; to the best of the information provided, there is no requirement for travel.

Science & Healthcare
Industry
10,001+
Employees

Mission & Purpose

When it comes to your health, everything matters. That’s why UnitedHealthcare is helping people live healthier lives and making the health system work better for everyone. Our health plans are there for you in moments big and small, delivering a simple experience, affordable coverage, and supportive care. Wherever your health takes you, we're there for what matters. At UnitedHealthcare, part of the UnitedHealth Group family of businesses, we are working to create a system that is connected, aligned and more affordable for all involved; one that delivers high quality care, responsive to the needs of each person and the communities in which they live. With connections to more than 1.3 million physicians and care professionals and 6,500 hospitals and care facilities across the globe, we can collaborate in new ways to improve patient care while providing customizable and comprehensive solutions in any marketplace, anywhere.

Culture & Values

  • Integrity

    Honor commitments. Never compromise ethics.

  • Compassion

    Walk in the shoes of the people we serve and those with whom we work.

  • Relationships

    Build trust through collaboration.

  • Innovation

    Invent the future. Learn from the past

  • Performance

    Demonstrate excellence in everything we do.

Benefits

  • United Well-being

    United Well-being supports employees in their journey to better health. Resources include: Exercise and mindfulness apps. Tips and recipes for healthy cooking. Wellness coaching and financial tools. A private employee community group.

  • Health and Insurance

    Our medical plans for employees deliver better value and better outcomes. We offer: Copay plans and HSA-eligible plans. Vision and dental plans. Flexible spending accounts. Life insurance, and more.

  • Savings and Retirement

    In addition to competitive pay, we provide financial benefits to help employees manage their money. Benefits include: 401(k) Savings Plan. Employee Stock Purchase Plan. UnitedHealth Group credit union, and more.

  • Paid Time Off (PTO)

  • Paid Company Holidays

  • Parental Leave

  • Employee Assistance Program