Medical Director Utilization Management - Tennessee - Remote

Optum; Nashville (NC); Remote; USD 150,000 - 250,000; Full time

Job summary

An established industry player is seeking a Medical Director to enhance health outcomes through clinical support and collaboration. This role involves conducting coverage reviews, collaborating with healthcare providers, and ensuring cost-effective quality medical care for members. The ideal candidate will have a strong clinical background, excellent communication skills, and a commitment to improving health equity. Enjoy the flexibility of remote work while making a significant impact in the healthcare field. Join a team dedicated to advancing health outcomes and equity for all.

Qualifications

• 5+ years of clinical practice experience after residency training.
• Active unrestricted license to practice medicine in Tennessee.

Responsibilities

• Conduct coverage reviews and render coverage determinations.
• Document clinical review findings in accordance with policies.

Skills

Evidence Based Medicine (EBM)

Oral communication skills

Written communication skills

Interpersonal communication skills

Problem-solving skills

Education

M.D or D.O.

Board certification in Internal Medicine, Family Medicine, or Emergency Medicine

Board certification in Gastroenterology, Cardiology or Rheumatology

Tools

MS Word

Outlook

Excel

Job description

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.

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

Required Qualifications:

• M.D or D.O.
• Board certification in Internal Medicine, Family Medicine, or Emergency Medicine
• Active unrestricted license to practice medicine in the state of Tennessee
• Must reside in the state of Tennessee
• 5+ years of clinical practice experience after completing residency training
• Sound understanding of Evidence Based Medicine (EBM)
• PC skills, specifically using MS Word, Outlook, and Excel
• Willing to obtain additional licenses as needed
• Willing to participate in rotational holiday and call coverage

Preferred Qualifications:

• Board certification in either Gastroenterology, Cardiology or Rheumatology a plus
• Experience in utilization and clinical coverage review
• Proven excellent oral, written, and interpersonal communication skills, facilitation skills
• Data analysis and interpretation aptitude
• Innovative problem-solving skills
• Presentation skills for both clinical and non-clinical audiences

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

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.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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