Remote Medical Director, Claims & Utilization Review

RXinsider LTD.; Atlanta (GA); Remote; USD 249,000 - 373,000; Full time

Job summary

UnitedHealth Group (Optum) is seeking a Medical Director to provide physician support to Enterprise Clinical Services, shaping clinical coverage determinations, quality improvement, and cost-effective care for members. You will collaborate with network and non-network physicians to ensure compliant, evidence-based decisions.

You will lead clinical rounds, communicate effectively, and drive patient-centered care while advancing operational policies in a large, multi-disciplinary team.

Qualifications

• MD or DO degree required.
• Active unrestricted medical license and ability to obtain additional state licenses as needed.
• Current board certification in Medicine through ABMS or AOA.
• 5+ years of physician clinical practice experience after completing residency training.
• Proven understanding of Evidence Based Medicine (EBM).
• Proficient with MS Word, Outlook, and Excel.

Responsibilities

• Conduct coverage reviews based on member plan benefits and national and proprietary review policies, render coverage determinations.
• Document clinical review findings, actions, and outcomes in accordance with policies and regulatory requirements.
• Engage with requesting providers as needed in peer-to-peer discussions.
• Interpret existing benefit language and policies in clinical coverage reviews.
• Participate in daily clinical rounds as requested.
• Communicate with network and non-network providers to ensure accurate, timely benefit determinations.

Skills

Evidence Based Medicine

MS Word

Outlook

Excel

Education

MD or DO degree

Board Certification in Medicine (ABMS/AOA)

Tools

MS Word

Outlook

Excel

Job description

UnitedHealth Group (Optum) is seeking a Medical Director to provide physician support to Enterprise Clinical Services, shaping clinical coverage determinations, quality improvement, and cost-effective care for members. You will collaborate with network and non-network physicians to ensure compliant, evidence-based decisions.

You will lead clinical rounds, communicate effectively, and drive patient-centered care while advancing operational policies in a large, multi-disciplinary team.