Remote Medical Director, Pediatrics & Utilization

Sustainable World, Inc.; Houston, Northern (TX, KY); Hybrid; USD 249,000 - 373,000; Full time

Job summary

UnitedHealth Group is seeking a Medical Director to provide physician support for Enterprise Clinical Services, focusing on pre-service coverage determinations and medical necessity decisions. You will collaborate with network and non-network physicians, lead clinical reviews, and participate in rounds to ensure cost-effective, high-quality care.

Responsibilities include documenting findings, communicating policies, and guiding providers through benefit plans.

Qualifications

• MD or DO with board certification in ABMS or AOA.
• Active unrestricted medical license and ability to obtain additional state medical licenses.
• 5+ years of clinical practice after residency.
• Solid understanding of Evidence Based Medicine (EBM).
• Proficient in MS Word, Outlook, and Excel.

Responsibilities

• Conduct coverage reviews based on member plan benefits and policies; render determinations.
• Document clinical review findings in accordance with policies and requirements.
• Engage with requesting providers in peer-to-peer discussions.
• Interpret benefit language and policies in clinical reviews.
• Participate in daily clinical rounds as requested.
• Collaborate with network and non-network providers for timely determinations.
• Participate in holiday and call coverage rotation.

Skills

EBM knowledge

MS Word

Outlook

Excel

Education

MD or DO

Job description

UnitedHealth Group is seeking a Medical Director to provide physician support for Enterprise Clinical Services, focusing on pre-service coverage determinations and medical necessity decisions. You will collaborate with network and non-network physicians, lead clinical reviews, and participate in rounds to ensure cost-effective, high-quality care.

Responsibilities include documenting findings, communicating policies, and guiding providers through benefit plans.