[Hiring] Medical Claims Review Medical Director @UnitedHealth Group

Role Description

The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical Services. The Medical Director collaborates with Enterprise Clinical Services leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on post-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well as other Enterprise Clinical Services.

The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member’s primary care provider or specialist physician. It is the primary responsibility of the medical director physician to ensure that the appropriate and most cost effective quality medical care is provided to members.

• 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
• Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
• Participate in daily clinical rounds as requested
• Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
• Communicate and collaborate with other internal partners

Qualifications

• M.D. or D.O.
• Active unrestricted medical license and ability to obtain additional state medical licenses as needed
• Current board certification in Medicine through ABMS or AOA
• 5+ years of physician clinical practice experience after completing residency training
• Proven sound understanding of Evidence Based Medicine (EBM)
• Demonstrated PC skills, specifically using MS Word, Outlook, and Excel

Requirements

• Compact License
• Experience in utilization review
• Demonstrated data analysis and interpretation aptitude
• Proven innovative problem-solving skills
• Proven excellent presentation skills for both clinical and non-clinical audiences
• Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skills

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)