Medical Director Utilization Management - Remote

Lensa; Dallas (TX); Remote; USD 238,000 - 358,000; Full time

Job summary

A leading healthcare organization is seeking a Medical Director to oversee clinical reviews and ensure quality medical care for members. This role involves collaborating with a multidisciplinary team and engaging with providers to deliver effective healthcare solutions. The position offers remote flexibility within the U.S. and a competitive salary range, along with comprehensive benefits and development opportunities.

Benefits

Comprehensive benefits package

Incentive programs

Stock options

401k contributions

Qualifications

• 5+ years of clinical practice experience post-residency.
• Strong understanding of Evidence Based Medicine (EBM).

Responsibilities

• Conduct coverage reviews based on individual member plan benefits.
• Document clinical review findings in accordance with policies.
• Engage with requesting providers in peer-to-peer discussions.

Skills

Evidence Based Medicine

Communication

Problem-solving

Education

M.D or D.O.

Board certification in Internal Medicine

Tools

MS Word

Outlook

Excel

Job description

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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. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs.

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 services for members. The activities primarily focus on clinical knowledge application in utilization management activities, including pre-service benefit and coverage determinations or medical necessity assessments, and communication with network and non-network physicians.

The Medical Director collaborates with a multidisciplinary team and manages medical benefits, often involving the member’s primary care provider or specialist physician. The primary responsibility is to ensure the delivery of appropriate and cost-effective quality medical care 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

1. Conduct coverage reviews based on individual member plan benefits and policies, and render coverage determinations.
2. Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements.
3. Engage with requesting providers as needed in peer-to-peer discussions.
4. Interpret existing benefit language and policies during clinical coverage reviews.
5. Participate in daily clinical rounds as requested.
6. Communicate and collaborate with network and non-network providers to ensure accurate and timely benefit determinations, while educating providers on benefit plans and medical policy.
7. Collaborate with internal partners.
8. Participate in holiday and call coverage rotation.

You’ll be rewarded and recognized for your performance in an environment that challenges you, provides clear success criteria, and offers development opportunities.

Required Qualifications

• M.D or D.O.
• Board certification in Internal Medicine, Family Medicine, or Emergency Medicine.
• Willing to obtain additional licenses as needed.
• 5+ years of clinical practice experience post-residency.
• Strong understanding of Evidence Based Medicine (EBM).
• Proficiency in MS Word, Outlook, and Excel.
• Ability to participate in rotational holiday and call coverage.

Preferred Qualifications

• Experience in utilization and clinical coverage review.
• Excellent communication, facilitation, and interpersonal skills.
• Data analysis and interpretation skills.
• Problem-solving skills.
• Presentation skills for clinical and non-clinical audiences.
• Remote employees must adhere to UnitedHealth Group’s Telecommuter Policy.

The salary range for this role is $238,000 to $357,500 per year, based on experience and achievement. Benefits include a comprehensive package, incentive programs, stock options, and 401k contributions. The application deadline is a minimum of 2 business days or until a sufficient candidate pool is reached.

Our mission is to help people live healthier lives and improve health equity, addressing disparities experienced by marginalized groups. We are committed to environmental sustainability and equitable care.

UnitedHealth Group is an Equal Employment Opportunity employer and a drug-free workplace, requiring drug testing prior to employment.