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

Perform initial and concurrent review of inpatient cases applying evidenced based criteria (InterQual criteria) Discuss cases with facility healthcare professionals to obtain plans of care Collaborate with Optum Enterprise Clinical Services Medical Directors on performing utilization management Participation in discussions with the Clinical Services team to improve the pr

The UnitedHealthcare Community Plan of DC proudly serves the Dual Eligible Special Needs (D SNP) population in the District of Columbia and is excited to recruit for our leader of clinical oversight. This individual contributor will report directly to the Executive Director and will support them on coordinating select priorities, as well as have accountability in two key

Partner with clinical care coordination team to manage complex members in the community Seek and find members in the community who have been labeled unable to reach Conduct assessments as needed, i.e., health risk assessment Perform targeted activities to complete care plan interventions and to support STAR gap closure Proactively engage the member to manage their care Pa

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Set strategy for experience improvement that supports FP member NPS and retention goals Establish a culture focused on our people obsessed with continual improvements to our members' experience Present strategy to senior management and measure against the strategy Identify, develop, and support the implementation of operational process changes & innovative solutions that

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Addresses the total patient, inclusive of medical, psychosocial, behavioral, cultural, and spiritual needs Involves the individual patient and caregiver, as appropriate, in decision making Facilitates communication and coordination among members of the care team Provides patient care to include patient assessment prior to physician's/nurse practitioner's examination, serv

Care Management allocation Care Management responsibilities 80% time allocation which includes case consultations with a case load of 45 50 Utilization of hotspotting tool and other internal resource tools that identify at risk AI members Community, relationship building, education 20% (Interventions and efforts to be logged and tracked, reviewed with Manager, including o

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Sending correspondence to members Reconciling reports Performing basic data entry functions with proficient PC skills including but not limited to Microsoft products and Quickbooks Analytical and Researching techniques Initiate and assist with developments / changes to increase or change quality and productivity Preparing, processing, and maintaining new member or group e

Manages a caseload by coordinating services and collaborating with other health care professionals in the provision of health care services for injured workers Determines the necessity and appropriateness of health care services for patients Evaluates and reports on outcomes Provides Health Education, coaching and treatment decision support for injured workers Meets with

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Perform utilization review determinations for radiation oncology populations, and support case and disease management teams to achieve optimal clinical outcomes Speak with providers by phone. This will include discussion of evidence based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expense Enhance c

As part of a multi disciplinary care coordination team Addresses the total patient, inclusive of medical, psychosocial, behavioral, cultural, and spiritual needs Involves the individual patient and caregiver, as appropriate, in decision making Facilitates communication and coordination among members of the care team Provides patient care to include patient assessment prio