Medical Director Utilization Management - Remote
Optum
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 directly improves 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.
Clinical Advocacy & Support focuses on the customer journey, ensuring we exceed expectations by delivering clinical coverage and medical claims reviews. We empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, provide a seamless experience, and manage health care costs.
The Medical Director provides physician support to Enterprise Clinical Services operations, overseeing the initial clinical review of service requests. The role collaborates with leadership and staff to establish, implement, support, and maintain clinical and operational processes related to benefit coverage determinations, quality improvement, and cost effectiveness of services for members. Activities focus on applying clinical knowledge in utilization management, especially pre‑service benefit and coverage determinations or medical necessity. The director communicates with network and non‑network physicians and other internal partners to ensure the most cost‑effective, high‑quality medical care for members.
You will enjoy the flexibility to work remotely from anywhere within the U.S. while taking on challenging responsibilities.
Primary Responsibilities
Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations.
Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements.
Engage with requesting providers as needed in peer‑to‑peer discussions.
Interpret existing benefit language and policies in the process of clinical coverage reviews.
Participate in daily clinical rounds as requested.
Collaborate with network and non‑network providers to achieve accurate and timely benefit determinations, educating providers on benefit plans and medical policy.
Collaborate with other internal partners.
Participate in holiday and call coverage rotation.
Required Qualifications
M.D. or D.O.
Active board certification in an ABMS or AOBMS specialty.
Active unrestricted medical license and ability to obtain additional state medical licenses as needed.
5+ years of clinical practice experience after completing residency training.
Proven understanding of Evidence Based Medicine (EBM).
Proficient PC skills, specifically using MS Word, Outlook, and Excel.
Ability to participate in rotational holiday and call coverage.
Preferred Qualifications
Board certification in Gastroenterology, Cardiology, Endocrinology, or radiation oncology (other specialties considered).
Experience in utilization and clinical coverage review.
Reside in Nebraska or Texas.
Excellent oral, written, and interpersonal communication skills, facilitation skills.
Data analysis and interpretation aptitude.
Innovative problem‑solving skills.
Presentation skills for both clinical and non‑clinical audiences.
All employees working remotely required to adhere to UnitedHealth Group's Telecommuter Policy.
Compensation and Benefits
Compensation ranges from $238,000 – $357,500 annual salary, plus base pay and bonus. Benefits include a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. All benefits are subject to eligibility requirements.
Application Deadline
This position is posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. The job posting may close early due to volume of applicants.
Equal Employment Opportunity
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.