UnitedHealth Group is a healthcare and well-being company that’s dedicated to improving the health outcomes of millions around the world. We are comprised of
Appeals and Grievances Medical Director Reconsiderations
Location
United States
Posted
74 days ago
Salary
$248.5K - $373K / year
Seniority
Lead
No structured requirement data.
Job Description
Appeals and Grievances Medical Director Reconsiderations
UnitedHealth Group
Role Description 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 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. 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 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. 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. Qualifications - MD or DO with an active, unrestricted license - Board Certified in an ABMS or AOBMS specialty - No Pediatricians - 5+ years of clinical practice experience - 2+ years of Quality Management experience - Intermediate or higher level of proficiency with managed care - Basic computer skills, typing, word processing, presentation, and spreadsheet applications skills - Internet researching skills - Proven excellent presentation skills for both clinical and non-clinical audiences - Familiarity with current medical issues and practices - Proven excellent telephonic communication skills; excellent interpersonal communication skills - Proven excellent project management skills - Proven data analysis and interpretation skills - Proven creative problem-solving skills - Proven solid team player and team building skills Requirements - All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy Benefits - Compensation for this specialty generally ranges from $248,500.00 - $373,000.00. - 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 us, 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.
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Overview The Medical Science Liaison (MSL) is a field-based representative of the Medical Affairs Organization that supports and represents Shionogi Inc and its products with, and to, key opinion leaders (KOLs), clinicians, institutions, and professional organizations. This includes relationship building and management of KOLs providing for meaningful scientific exchange at national, regional and local levels in both academic and clinical practice settings. The incumbent addresses the specific needs of healthcare professionals (HCPs) by responding to unsolicited requests for information about our marketed and developing products. As a clinical and scientific expert on the company and products, the MSL is responsible for building long-term relationships and establishing rapport with HCPs in hospitals, clinics, and academic centers through scientific disease state and product discussions that support current therapeutic concepts and ensure the safe and effective use of products. The incumbent is also a resource to company management regarding therapeutic area dynamics, business development, and KOL feedback. The MSL also works cross-functionally with internal departments and external resources on clinical and scientific matters. At all times, the MSL fully complies with all applicable federal, state, and local laws and regulations as well as Shionogi Inc. Code of Conduct. policies, standards, work instructions, privacy and data guidelines. Responsibilities Responsibilities The following outlines the main duties of the role. This summary is not meant to be an exhaustive, but provides a high-level overview of the key activities of the role. - Establishes, manages, and maintains successful relationships with relevant healthcare entities including, but not limited to, KOLs, HCPs, academic institutions, payors, patient organizations, etc. to serve as the educational, research and clinical/scientific informational resource. - Designs and executes plans for the assigned MSL region with alignment to medical strategy and KOL priorities. - Identify relevant HCPs in context of medical strategy and patient needs. - Responds to and documents unsolicited medical and scientific requests for information; Liaises with investigators on unsolicited requests for investigator-initiated research submissions studies. - Delivers, and may develop/design, fair-balanced clinical and scientific presentations for HCPs, payors, and patient organizations in response to unsolicited requests for information on company products with with medical review committee approval. - Identifies and trains speakers for advisory boards, symposia, and educational programs with presentation materials, including approved slide sets, abstracts, posters, etc. - Attends national and regional medical/scientific meetings and symposia as a representative of the company and engages in discussions with attendees as appropriate; attends scientific sessions and poster presentations, gathers information, and summarizes findings; as appropriate, cultivates professional relationships from interactions at these meeting. - Evaluates competitor research and information relevant to company therapeutic areas, objectives, activities, and product priorities; stays current on therapeutic advances; analyzes and applies relevant intelligence findings and presents data/insight to appropriate internal stakeholders. - Collaborates and works effectively across multi-disciplinary internal groups (Clinical, Regulatory, Commercial (Sales and Marketing), Legal, Compliance, etc.) to support Shionogi medical/scientific and business objectives. This includes providing disease state, clinical and scientific training as requested across functional teams and providing input to management on therapeutic and research advances, business development opportunities/risks, and KOL feedback. - Maintains a thorough awareness of medical/clinical, regulatory, compliance, and quality issues and processes as they apply to the Company’s therapeutic areas and adheres to, and supports the standards established by the company. - Completes accurate and timely submission of administrative reports, projects, expense reports, training, KOL documentation, conference reports, and all other required documentation. - Analyzes operational data to identify trends, root causes, and opportunities for improvement. 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If you are qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to use or access this website to apply for a vacancy as a result of your disability. You can request accommodations by calling 973-307-3550 or by sending an email to ShionogiHR@shionogi.com.
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Medical Records Clerk
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