Medical Claims Review Medical Director - Remote in United States

UnitedHealth Group•St. Louis, MO

1d•$248,500 - $373,000•Remote

About The Position

Optum is seeking a Medical Director to provide physician support to Enterprise Clinical Services, which performs initial clinical reviews of service requests. The role 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-effective member services. The position primarily applies clinical knowledge to utilization management, with a focus on post-service benefit and coverage determinations or medical necessity according to the member’s benefit package. The Medical Director communicates about these determinations with network and non-network physicians and other Enterprise Clinical Services partners. Working with a multidisciplinary team, the physician helps ensure members receive appropriate, cost-effective, quality medical care. This role is remote from anywhere in the United States. Remote employees must adhere to UnitedHealth Group’s Telecommuter Policy.

Requirements

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

Nice To Haves

Compact License.
Experience in utilization review.
Data analysis and interpretation aptitude.
Innovative problem-solving skills.
Presentation skills for clinical and non-clinical audiences.
Oral, written, interpersonal communication, and facilitation skills.

Responsibilities

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, and render coverage determinations.
Document clinical review findings, actions, and outcomes in accordance with policies and regulatory and accreditation requirements.
Engage with requesting providers in peer-to-peer discussions as needed.
Interpret existing benefit language and policies during clinical coverage reviews.
Participate in daily clinical rounds as requested.
Communicate and collaborate with network and non-network providers to support accurate and timely benefit determinations and educate providers on benefit plans and medical policy.
Communicate and collaborate with internal partners.