Clinical Review Medical Director - Neurology - Remote

UnitedHealth Group•Springfield, MA

19h•Remote

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The Clinical Advocacy & Support team focuses on the customer journey, ensuring expectations are exceeded in delivering clinical coverage and medical claims reviews. Their role is to empower providers and members with tools and information to improve health outcomes, reduce care variation, deliver seamless experience, and manage healthcare costs. The Medical Director provides physician support to Enterprise Clinical Services operations, which is responsible for the initial clinical review of service requests. This role involves collaborating 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 applying 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, often involving the member’s primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that appropriate and most cost-effective quality medical care is provided to members.

Requirements

M.D or D.O.
Active unrestricted license to practice medicine
Board Certification in Neurology
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

Nice To Haves

Licensed in MA or MN
Utilization Management or clinical coverage review experience for an insurance or managed care organization
Proven data analysis and interpretation aptitude
Proven innovative problem-solving skills
Demonstrated excellent presentation skills for both clinical and non-clinical audiences
Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skills
Willing to obtain additional licensures if needed

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