Medical Director, Utilization Management Physician - Optum - Remote

ISHE; San Antonio, Northern (TX, KY); Hybrid; USD 249,000 - 373,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

WellMed, part of the Optum family, seeks a Medical Director for Utilization Management to lead and optimize our UM program. This role focuses on medical necessity, CMS criteria, and program improvements while fostering a collaborative, remote-friendly work environment across the U.S.

You will drive utilization management initiatives, monitor trends, and provide guidance to physicians and staff to ensure compliant, high-quality patient care.

Qualifications

• MD/DO/MBBS degree required
• Board certification in Family Medicine, Internal Medicine, or Emergency Medicine
• Active, unrestricted medical license in any state
• 5+ years of post-residency clinic practice experience
• Proficiency with Microsoft Office applications
• Bilingual English/Spanish preferred

Responsibilities

• Develop and maintain an efficient Utilization Management program for health plan members
• Stay current with CMS criteria hierarchy and organizational determination processes
• Participate in case reviews and medical necessity determinations
• Ensure compliance with CMS and delegated health plans regulations
• Conduct post-service reviews for medical necessity and benefit determination coding
• Develop medical management, care management, and utilization management protocols
• Attend physician meetings and orient new physicians to policies and resources
• Support growth and development of staff within the UM department
• Provide education on medical technologies, review criteria, and UM policies

Skills

Bilingual English/Spanish

MS Office proficiency

Education

MD/DO/MBBS

Active unrestricted medical license

Job description

WellMed, part of the Optum family of businesses, is seeking an internal medicine or family medicine physician to join our Utilization Management team. Optum is a clinician-led care organization that is changing the way clinicians work and live.

The Medical Director for Utilization Management will support WellMed Medical Management, Inc. by making utilization management determinations, identifying utilization trends suggesting possible over or under utilization of services and proactively suggesting improvements to WellMed Medical Management's utilization management program.

At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Position Highlights & Primary Responsibilities:

• Assists in development and maintaining an efficient UM program to meet the needs of the health plan members and commensurate with company values
• Remain current and proficient in CMS criteria hierarchy and organizational determination processes
• Participates in case review and medical necessity determination
• Maintain proficiency in compliance regulations for both CMS and delegated health plans
• Conducts post service reviews issued for medical necessity and benefits determination coding
• Assists in development of medical management, care management, and utilization management protocols
• Performs all other related duties as assigned

Customer Service:

• Oversees and ensures physician compliance with UM plan
• Performs all duties in a professional and responsible manner
• Responds to physicians and staff in a prompt, pleasant and professional manner
• Respects physician, patient, and organizational confidentiality
• Provides quality assurance and education of current medical technologies, review criteria, accepted practice of medicine guidelines, and UM policies and procedures with counsel when criterion are not met
• Personal and Physician Development
• Strives to personally expand working knowledge of all aspects of the UM department
• An active participant in physician meetings
• Orients new physicians to ensure understanding of company policy and resources available for physician support
• Assists in the growth and development of subordinates by sharing special knowledge for others and promotes continued education classes
• Attends continuing education classes to keep abreast of medical advancements and innovative practice guidelines

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. At WellMed our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or M.B.B.S.
• Board certification in Family Medicine, Internal Medicine, or emergency medicine
• An active, unrestricted medical license (any state)
• 5+ years of post-residency clinic practice experience
• Proficiency with Microsoft Office applications

Preferred Qualifications:

• 2+ years of experience in utilization management activities
• 2+ years of experience with acute admissions
• 2+ years of experience working in a managed care health plan environment
• Bilingual (English/Spanish) fluency

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $248,500.00 to $373,000.00 annually based on full-time employment. We comply with all minimum wage laws as applicable.

• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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.

OptumCare 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.