UM Medical Director - Surgical Specialty - Remote

Optum; Atlanta (GA); Remote; 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 coverage determinations and medical necessity reviews. You will collaborate with leadership and staff to implement clinical and operational processes for cost-effective care.

You’ll work with network and non-network physicians and participate in clinical rounds, with remote work available across the U.S.

Qualifications

• MD or DO required and licensed to practice medicine.
• Board certification in a surgical specialty (ABMS/AOA).
• Active unrestricted medical license with ability to obtain more licenses.
• 5+ years clinical practice after residency.
• Solid understanding of Evidence Based Medicine (EBM).
• Strong MS Word, Outlook and Excel skills.
• Ability to participate in rotational holiday and call coverage.

Responsibilities

• Conduct coverage reviews based on member plan benefits and policies, render determinations.
• Document findings and outcomes per policies and regulatory requirements.
• Engage with requesting providers in peer-to-peer discussions as needed.
• Interpret benefit language and policies during clinical reviews.
• Participate in daily clinical rounds as requested.
• Collaborate with network and non-network providers to pursue timely determinations.
• Coordinate with internal partners and participate in holiday/call coverage.

Skills

Clinical leadership

Evidence Based Medicine

Regulatory compliance

Education

MD/DO

Board certification in surgical specialty (ABMS or AOA)

Tools

MS Word

Outlook

Excel

Job description

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 in making healthcare work better for everyone through people-led, responsible AI while 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. 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.

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
• Participate in holiday and call coverage

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.
• Board certification in any surgical specialty through the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)
• Active unrestricted medical license and ability to obtain additional state medical licenses as needed
• 5+ years of clinical practice experience after completing residency training
• Proven sound understanding of Evidence Based Medicine (EBM)
• Proven solid PC skills, specifically using MS Word, Outlook, and Excel
• Ability to participate in rotational holiday and call coverage

Preferred Qualifications

• Experience in utilization and clinical coverage review
• Reside in Nebraska or Texas
• Licensure in TX. IN, KS, NE, AZ, WA, FL or a compact license
• Proven excellent oral, written, and interpersonal communication skills, facilitation skills
• Demonstrated data analysis and interpretation aptitude
• Proven innovative problem-solving skills
• Demonstrated presentation skills for both clinical and non-clinical audiences
• 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 - $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.