Medical Director - Clinical Advocacy and Support - Hawaii preferred - Remote

Lensa; Los Angeles (CA); Remote; USD 238,000 - 358,000; Full time

Job summary

A leading healthcare organization is seeking a Medical Director for Clinical Advocacy and Support, preferably based in Hawaii but open to remote work across the U.S. This role involves overseeing clinical reviews, engaging with providers, and ensuring quality care for members. Candidates must hold an M.D. or D.O. license and have board certification in an ABMS specialty, with a strong understanding of Evidence-Based Medicine. The position offers a competitive salary and comprehensive benefits.

Benefits

Comprehensive health plans

Incentives

Stock purchase options

401(k)

Qualifications

• At least 3 years of clinical practice post-residency.
• Strong understanding of Evidence-Based Medicine (EBM).
• Excellent communication and facilitation skills.

Responsibilities

• Conduct coverage reviews based on member benefits and policies.
• Engage in peer-to-peer discussions with requesting providers.
• Document review findings and communicate with providers.

Skills

Evidence-Based Medicine

Communication

Data Analysis

Problem-Solving

Presentation Skills

Education

M.D. or D.O. license

Board certification in an ABMS specialty

Tools

MS Word

Outlook

Excel

Job description

Medical Director - Clinical Advocacy and Support - Hawaii preferred - Remote

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Lensa is the leading career site for job seekers at every stage of their career. Our client, UnitedHealth Group, is seeking professionals. Apply via Lensa today!

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 will directly improve 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 diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Join us to make an impact on the communities we serve as you help us advance health equity on a global scale. Come make a difference in healthcare with us.

Clinical Advocacy & Support focuses on the customer journey, ensuring we exceed expectations through clinical coverage and medical claims reviews. Our goal is to empower providers and members with tools and information to improve health outcomes, reduce care variation, deliver seamless experiences, and manage healthcare costs.

The Medical Director provides physician support to Enterprise Clinical Services operations, overseeing the clinical review of service requests. The role involves collaborating with leadership to establish and maintain processes related to benefit coverage, quality improvement, and cost-effectiveness. The focus is on utilization management activities, including pre-service benefit and coverage determinations or medical necessity assessments, and communicating these to network and non-network physicians.

The Medical Director works with a multidisciplinary team, managing medical benefits and engaging with primary care or specialist physicians to ensure cost-effective, quality medical care for members.

This position offers the flexibility to work remotely from anywhere within the U.S., tackling challenging healthcare issues.

Primary Responsibilities

• Conduct coverage reviews based on member benefits and policies, and render determinations.
• Document review findings, actions, and outcomes per policies and regulations.
• Engage in peer-to-peer discussions with requesting providers as needed.
• Interpret existing benefit language and policies during reviews.
• Participate in virtual clinical rounds as required.
• Communicate with providers and internal partners to ensure accurate, timely benefit determinations and educate providers on policies.
• Participate in call coverage rotations.

Required Qualifications

• M.D. or D.O. license, active and unrestricted.
• Board certification in an ABMS specialty; Internal Medicine preferred, but other specialties like General Surgery, Rheumatology, ER, Family Medicine, ENT, or PM&R are considered.
• At least 3 years of clinical practice post-residency.
• Strong understanding of Evidence-Based Medicine (EBM).
• Proficiency with MS Word, Outlook, and Excel.

Preferred Qualifications

• Hawaii residence and license preferred but not required.
• Experience in utilization and clinical coverage review.
• Excellent communication, facilitation, data analysis, problem-solving, and presentation skills.
• Remote employees must adhere to UnitedHealth Group’s Telecommuter Policy.

The salary range is $238,000 to $357,500 annually, based on experience and performance metrics, with additional benefits including comprehensive health plans, incentives, stock purchase options, and 401(k).