[Hiring] Medical Director Utilization Management @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 pre-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 to ensure that the appropriate and most cost-effective quality medical care is provided to members.

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.
• 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.
• Participate in holiday and call coverage rotation.

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 sound understanding of Evidence Based Medicine (EBM).
• Proven solid PC skills, specifically using MS Word, Outlook, and Excel.
• Ability to participate in rotational holiday and call coverage.

Requirements

• Board certification in either Gastroenterology, Cardiology, Endocrinology, radiation oncology (other specialties will be considered).
• Experience in utilization and clinical coverage review.
• Reside in Nebraska or Texas.
• Licensure in TX, IN, KS, NE, AZ, WA, FL or a compact license.
• Proven excellent oral, written, and interpersonal communication skills, facilitation skills.
• Demonstrated data analysis and interpretation aptitude.
• Proven innovative problem-solving skills.
• Demonstrated presentation skills for both clinical and non-clinical audiences.

Benefits

• Compensation generally ranges from $248,500 to $373,000.
• 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.
• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

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.