Remote Medical Director: Utilization & Coverage Strategy

Texas Health Institute; Boston, Northern (MA, KY); Hybrid; USD 249,000 - 373,000; Full time

Job summary

Optum is seeking a Medical Director to provide physician support for Enterprise Clinical Services, focusing on pre-service benefit determinations and medical necessity reviews. The role collaborates with leadership to maintain clinical and operational processes, ensuring high-quality, cost-effective care for members.

The position offers remote work within the United States, with responsibilities spanning clinical review, policy interpretation, and cross-functional collaboration with providers

Qualifications

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

Responsibilities

• Conduct coverage reviews based on member plan benefits and review policies; render coverage determinations.
• Document clinical review findings, actions, and outcomes per policy and regulations.
• Engage with requesting providers in peer-to-peer discussions as needed.
• Interpret benefit language and policies during clinical coverage reviews.
• Participate in daily clinical rounds as requested.
• Collaborate with network and non-network providers to ensure accurate benefit determinations and educate on plans and medical policy.
• Collaborate with internal partners and participate in holiday/call rotation.

Skills

Clinical experience

Evidence Based Medicine

Education

MD or DO

ABMS/AOA board cert

Tools

MS Word

Outlook

Excel

Job description

Optum is seeking a Medical Director to provide physician support for Enterprise Clinical Services, focusing on pre-service benefit determinations and medical necessity reviews. The role collaborates with leadership to maintain clinical and operational processes, ensuring high-quality, cost-effective care for members.

The position offers remote work within the United States, with responsibilities spanning clinical review, policy interpretation, and cross-functional collaboration with providers