Clinical Assessment Review Expert Sr Medical Director - Remote

UnitedHealth Group•Tampa, FL

22d•$200,000 - $350,000•Remote

About The Position

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Together with the clinical RN team, evaluate clinical program effectiveness, including technology enhancements by performing utilization management clinical chart reviews to ensure consistency and accuracy of clinical decisions Make recommendations to optimize clinical programs to UCS Medical Management leadership based on current and future end-to-end process and criteria Provide LOB Chief Medical Officers with timely clinical consistency data to aid in network negotiations and monitor responses to provider and market feedback Appropriately represent historical trends, gaps, deficiencies, and risks Serve as a subject matter expert on the appropriate application of nationally recognized clinical guidelines and criteria Identify root cause and solution development including documenting recommendations for change using data to effect positive change in utilization patterns Work with finance and functional partners on comprehensive operating reviews, including ROI and SG&A oversight Responsible for continuous process feedback to Optum clinical program operational leaders based on findings Associate Clinical Assessment & Review Expert: Perform clinical chart reviews to evaluate the impact of clinical programs, medical policies, processes, and to investigate utilization management trends, identified by health care economics (HCE) or as requested by senior leadership, to determine root causes Provide guidance and clinical expertise to inform process and performance improvement Serve as a key resource and provide explanation and information about chart review findings to others, including complex/critical issues Identify and communicate opportunities to optimize policies, processes, performance, and promote automation to leaders and impacted stakeholders Attend meetings with key stakeholders as assigned 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.

Requirements

MD or DO with an active, unrestricted medical license
Current Board Certification and maintenance in an ABMS or AOBMS specialty
5+ years clinical practice experience, including direct P&L responsibilities
5+ years of Utilization Management experience with demonstrated leadership role in provider or plan-based setting
Familiar with URAC and NCQA UM requirements
InterQual Certified Expert Resource or achieves within 6 months of accepting role
Proven ability to be self-motivated and independently problem solve, applying critical thinking strategies
Advanced proficiency in Microsoft applications
Designated workspace and access to install secure high-speed internet via cable/DSL in home
Travel may be required less than 10%25 of the time

Nice To Haves

MBA, MMM, or MPH
Experience presenting complex information to senior leaders
Prior Lead UM / CMIO / CMO role
Experience with clinical criteria and/or Medical Policy
Extremely detail oriented with focus on quality/quality assurance

Responsibilities

Together with the clinical RN team, evaluate clinical program effectiveness, including technology enhancements by performing utilization management clinical chart reviews to ensure consistency and accuracy of clinical decisions
Make recommendations to optimize clinical programs to UCS Medical Management leadership based on current and future end-to-end process and criteria
Provide LOB Chief Medical Officers with timely clinical consistency data to aid in network negotiations and monitor responses to provider and market feedback
Appropriately represent historical trends, gaps, deficiencies, and risks
Serve as a subject matter expert on the appropriate application of nationally recognized clinical guidelines and criteria
Identify root cause and solution development including documenting recommendations for change using data to effect positive change in utilization patterns
Work with finance and functional partners on comprehensive operating reviews, including ROI and SG&A oversight
Responsible for continuous process feedback to Optum clinical program operational leaders based on findings
Perform clinical chart reviews to evaluate the impact of clinical programs, medical policies, processes, and to investigate utilization management trends, identified by health care economics (HCE) or as requested by senior leadership, to determine root causes
Provide guidance and clinical expertise to inform process and performance improvement
Serve as a key resource and provide explanation and information about chart review findings to others, including complex/critical issues
Identify and communicate opportunities to optimize policies, processes, performance, and promote automation to leaders and impacted stakeholders
Attend meetings with key stakeholders as assigned