*This role will require the successful candidate to work the shift of Wednesday to Saturday, 10 AM to 9PM Eastern. The Appeal Review Clinician is responsible for handling appeals cases and relevant information. The scope of this job may include handling health plan and Medicare Quality Improvement Organization (QIO) appeals, including expedited appeals, reconsiderations and medical necessity reviews. This role ensures compliance with CMS regulations, organizational policies, and established clinical guidelines. Join us in shaping the future of healthcare - apply today! Key Responsibilities: - Review appeals submitted by members, providers, or authorized representatives related to denied authorizations, level of care determinations or coverage issues. - Classify appeals accurately once received. - Ensure each appeal meets regulatory, contractual and organizational filing requirements. - Meet the required turnaround times to submit appeal packages to the QIO. - Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes. - Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth. - Perform other job duties as assigned. Required Qualifications: - Bachelor's degree or equivalent work experience. - 4-6 years of clinical nursing or therapy experience. - Active RN, OT, or PT license. Preferred Qualifications: - 1-2 years' experience in utilization review, case management and/or managed care regulations. - Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes. Job Expectations: - Willing to work additional or irregular hours as needed. - Must work in accordance with applicable security policies and procedures to safeguard company and client information. - Must be able to sit and view a computer screen for extended periods of time. #LI-PG1 #LI-Remote WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference. WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace. Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates. Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky: - Excellent medical with Rx, dental, and vision benefits - Mental Health support through EAP - Generous paid time off, plus 13 paid holidays - 100% vested 401(K) retirement plans - Educational assistance up to $2500 per year

Purpose: The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director, Utilization Management role. The Medical Director, Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members. They will be responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. They will oversee adherence to quality and utilization standards through committee delegations and further establish an effective working relationship between UPMC Health Plan's Network and its physicians, hospitals and other providers. UPMC offers a premier benefits package, designed to care for your total well-being — physically, emotionally, and financially — paired with endless opportunities for career advancement and growth. Discover the culture, the teams, and the passions that drive us to make Life Changing Medicine happen. This is a Temporary Full-Time, Full-Remote role. Responsibilities: - Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns. - Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan.\ - Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management. - Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes. - Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures. - Contributes to process improvement within the Utilization Management department. - Participates in activities to support policy decision making. - Utilizes clinical experience to support departmental reviews. - This position requires a Doctor of Medicine or Doctor of Osteopathy from an accredited school - PA Medical license Required - The ideal candidate will have 5-10 years of clinical experience, as well as managed care experience - Internal Medicine, Family Medicine, or Emergency Medicine highly preferred - Licensure, Certifications, and Clearances: - Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO) - Pennsylvania Medical License UPMC is an Equal Opportunity Employer/Disability/Veteran

Requisition Number: 2349105 Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company. The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for Pain Management procedures ( e.g. spinal chord stimulators, pain pumps, nerve ablations, facet injections, etc.) - Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers) - Works with clinical staff to coordinate all the necessary UM processes and provides feedback to staff who do portions of the UM reviews - Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable - Discusses cases and clinical situations with treating providers telephonically during scheduled hours - Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews - Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews - Participate in rotational call coverage. Is available for occasional, periodic weekend and holiday as needed telephonic and remote computer expedited clinical decisions - Provide Clinical support for staff that conduct initial reviews - Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - Current, active, and fully unrestricted medical license - Current Board Certification and must maintain pain subspecialty with specialty in either PM&R or Anesthesia - 5+ years clinical experience post residency in Pain subspecialty - Proficient with MS Office (MS Word, Email, Excel, and Power Point) - Excellent computer skills and ability to learn new systems and software - Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel - Participate in rotational call coverage - Must be willing and able to obtain additional medical licenses as needed Preferred Qualifications: - License in North Carolina or New Mexico - Experience in managed care UM activities - Possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments - Experience with integration of clinical and financial data, development of utilization and performance reporting tools, and communication of performance data to physicians and other health care providers *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience, and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

• Lead the overall strategy, design, and execution of clinical and pre-clinical development programs • Develop scientifically rigorous clinical trial protocols and ensure regulatory and ethical compliance • Oversee preparation of core materials, including clinical development plans, regulatory submissions, and study documentation • Present program strategies and outcomes to internal and external stakeholders, including executive leadership and advisory boards • Collaborate with contract research organizations (CROs), academic partners, and cross-functional teams to ensure successful trial delivery • Partner with regulatory authorities and scientific collaborators to support study progress and milestone achievement • Manage budgets, timelines, and risks to ensure excellence in clinical program execution