Medical Director - Clinical Advocacy and Support - Specialty Surgery preferred - Remote

UnitedHealth Group•St. Louis, MO

12d•$248,500 - $373,000•Remote

About The Position

The Medical Director provides physician support to Enterprise Clinical Services operations, which is responsible for the initial clinical review of service requests. The role works with Enterprise Clinical Services leadership and staff to establish, implement, support, and maintain clinical and operational processes for benefit coverage determinations, quality improvement, and cost-effective member care. Activities focus on applying clinical knowledge to utilization management, particularly pre-service benefit and coverage determinations and medical necessity reviews based on the member’s benefit package, and communicating with network and non-network physicians and internal partners. The Medical Director collaborates with a multidisciplinary team, including members’ primary care providers and specialist physicians, and helps manage medical benefits. The role is responsible for ensuring members receive appropriate, cost-effective, quality medical care. This position can be performed remotely from anywhere in the United States, subject to UnitedHealth Group’s Telecommuter Policy.

Requirements

M.D. or D.O.
Active unrestricted license to practice medicine.
Active board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association.
At least 3 years of clinical practice experience after completing residency training.
Demonstrated sound understanding of Evidence Based Medicine (EBM).
Solid PC skills, specifically using MS Word, Outlook, and Excel.

Nice To Haves

Surgery specialty board certification; other board certifications such as Physiatry, Internal Medicine, Family Medicine, or Emergency Medicine may also be considered.
California, Oregon, Washington, or Arizona licensure, or willingness to obtain licensure if needed.
Experience in utilization and clinical coverage review.
Excellent oral, written, and interpersonal communication skills and facilitation skills.
Data analysis and interpretation aptitude.
Innovative problem-solving skills.
Excellent presentation skills for clinical and non-clinical audiences.

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 as needed in peer-to-peer discussions.
Interpret existing benefit language and policies during clinical coverage reviews.
Communicate and collaborate with network and non-network providers to support accurate and timely benefit determinations, while educating providers on benefit plans and medical policy.
Communicate and collaborate with internal partners.
Participate in a call coverage rotation.