Remote Medical Director, Utilization & Coverage

Sustainable World, Inc.; Boston, Northern (MA, 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 clinical coverage reviews, quality improvement, and cost-effective care for members.

This role collaborates with network and non-network providers, supports pre-service determinations, and requires an MD or DO, board certification, active license, 5+ years of practice, and strong skills in Evidence Based Medicine along with MS Word/Outlook/Excel.

Qualifications

• MD or DO degree required.
• Board certification by ABMS or AOA.
• Active unrestricted medical license.
• 5+ years of clinical practice after residency.
• Strong understanding of Evidence Based Medicine (EBM).
• Proficient in MS Word, Outlook and Excel.
• Willing to participate in rotational holiday and call coverage.

Responsibilities

• Conduct coverage reviews based on member plan benefits and national and proprietary coverage 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.
• 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 to pursue accurate and timely determinations and educate providers on benefits and medical policy.
• Communicate with other internal partners.
• Participate in holiday and call coverage rotation.

Skills

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 clinical coverage reviews, quality improvement, and cost-effective care for members.

This role collaborates with network and non-network providers, supports pre-service determinations, and requires an MD or DO, board certification, active license, 5+ years of practice, and strong skills in Evidence Based Medicine along with MS Word/Outlook/Excel.