UM Medical Director - DME - Remote in US

UnitedHealth Group; Houston (TX); Remote; USD 249,000 - 373,000; Full time

Job summary

UnitedHealth Group is seeking a UM Medical Director - DME for remote work in the United States. The role focuses on pre-service benefit coverage, medical necessity determinations, and collaboration with Enterprise Clinical Services leadership to ensure cost-effective, high-quality care.

The position requires MD/DO, an unrestricted license, and board certification in relevant specialties, with 5+ years of clinical practice.

Qualifications

• MD or DO required with medical license in good standing.
• Board certification in Physical Medicine & Rehabilitation, Internal Medicine, Family Medicine, general surgery, or orthopedic surgery.
• Active unrestricted license to practice medicine is required.

Responsibilities

• Conduct coverage reviews based on member benefits and policies; render coverage determinations.
• Document clinical review findings, actions, and outcomes per policy and regulatory requirements.
• Engage with requesting providers in peer-to-peer discussions as needed.
• Communicate benefit language and medical policy to providers to ensure timely determinations.
• Participate in daily clinical rounds and collaborate with network and non-network providers.

Skills

MS Word

Outlook

Excel

Education

MD or DO

Active unrestricted medical license

Board certification in PM&R/IM/FM/general surgery/ortho

Job description

Improve the lives of others while Caring. Connecting. Growing together.

Job Description - UM Medical Director - DME - Remote in US (2394222)

UM Medical Director - DME - Remote in US - 2394222

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs.

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 for all lines of business. 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. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week. Working in PST is preferred.

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
• Call coverage rotation

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• M.D or D.O
• Active unrestricted license to practice medicine
• Board certification in Physical Medicine & Rehabilitation, Internal Medicine, Family Medicine, general surgery, ortho surgery under American board or AOA board certifications
• 5+ years of clinical practice experience after completing residency training
• Sound understanding of Evidence Based Medicine (EBM)
• Proven solid PC skills, specifically using MS Word, Outlook, and Exceltrated PC skills, specifically using MS Word, Outlook, and Excel

Preferred Qualifications

• Multiple State Licenses
• Experience in utilization and clinical coverage review
• Data analysis and interpretation aptitude
• Innovative problem-solving skills
• Excellent oral, written, and interpersonal communication skills, facilitation skills
• Excellent presentation skills for both clinical and non-clinical audiences
• Reside in Pacific Time Zone

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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $248,500 to $373,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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 help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job

Clinical Analysis & Consulting

Primary Location

US-TX-Houston

Other Locations

US-CO-Denver, US-IL-Chicago, US-GA-Atlanta, US-AZ-Phoenix, US-CA-Los Angeles, US-MA-Boston, US-CA-San Diego, US-MO-Kansas City, US-WA-Seattle

UnitedHealth Group is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need special assistance or accommodation for any part of the application process, please call 1-866-566-8715 to be connected to Recruitment Services. Recruitment Services hours of operation are 7 a.m. to 7 p.m. CT, Monday through Friday.

UnitedHealth Group is a registered service mark of UnitedHealth Group, Inc. The UnitedHealth Group name with the dimensional logo, as well as the dimensional logo alone, are both service marks for the UnitedHealth Group, Inc.

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.