Medical Claims Review Medical Director-Internal Medicine - Remote

UnitedHealth Group•Tampa, FL

4h•$279,500 - $440,500•Remote

About The Position

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 post-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.

Requirements

M.D. or D.O.
Active unrestricted medical license and ability to obtain additional state medical licenses as needed
Current board certification in Internal Medicine through ABMS or AOA
5+ years of clinical practice experience after completing residency training
Proven sound understanding of Evidence Based Medicine (EBM)
Demonstrated PC skills, specifically using MS Word, Outlook, and Excel

Nice To Haves

Compact License
Experience in utilization review
Demonstrated data analysis and interpretation aptitude
Proven innovative problem-solving skills
Proven excellent presentation skills for both clinical and non-clinical audiences
Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skills

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