Utilization Management Medical Director- Remote

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 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. 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 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.
• Board certification American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)
• Active unrestricted license to practice medicine
• 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 Excel
• Proven ability and willingness to participate in rotational holiday and call coverage

Preferred Qualifications

• Licensed in Massachusetts desirable
• Board certification in Internal Medicine or Family Medication
• Experience in utilization and clinical coverage review
• Proven data analysis and interpretation aptitude
• Proven innovative problem-solving skills

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 make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is 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 is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.