Medical Director - UnitedHealthcare Community & State (Wisconsin)

UnitedHealth Group•Milwaukee, WI

3h•$248,500 - $373,000•Remote

About The Position

The Chief Medical Officer for UnitedHealthcare Community & State Wisconsin is an important clinical leadership role focused on improving quality, supporting thoughtful medical decision-making, and enhancing the member and provider experience across Medicaid, D-SNP, and LTC populations. Working closely with the Director of Clinical Operations and cross-functional partners, this role offers the opportunity to shape utilization management, quality improvement, provider collaboration, and population health efforts while helping ensure alignment with the Wisconsin DHS and ForwardHealth requirements and applicable state and federal regulations.

Requirements

MD or DO with an active, unrestricted Wisconsin medical license
Active/unrestricted Board certification in an ABMS/AOBMS Specialty
5+ years of post-residency clinical practice experience with strong clinical judgment
Proven solid communication skills and the ability to work effectively across clinical, operational, and provider-facing teams
Knowledge of Medicaid and Wisconsin ForwardHealth regulatory requirements
Experience with utilization management and medical decision-making
Commitment to quality improvement and population health outcomes
Ability to build strong provider and partner relationships
Collaborative leadership across cross-functional teams
Strategic thinking with strong operational follow-through

Nice To Haves

Experience in managed care, utilization management, and/or appeals and grievances
Experience supporting Medicaid, D-SNP, and/or LTC populations in a health plan, managed care, or value-based care setting
Experience building provider relationships and collaborating across teams in a matrixed environment
Knowledge of quality improvement, population health, and applicable regulatory requirements

Responsibilities

Provide clinical leadership for utilization management, prior authorization, appeals and grievances, and provider quality activities across Wisconsin Medicaid, LTC, and D-SNP populations
Support timely, evidence-based coverage decisions aligned with clinical guidelines, plan policies, and regulatory expectations
Partner with United Clinical Services and enterprise teams to support regulatory changes and strengthen clinical operations
Participate in clinical rounds, conduct peer-to-peer reviews, and represent the health plan in Medicaid fair hearings as appropriate
Review all member and provider appeals and grievances and provide clinical information and leadership to the weekly Appeals Panel Hearing calls
Contribute to performance goals related to HEDIS, STAR Ratings, CAHPS, and NPS
Identify care gaps and help advance evidence-based interventions that improve clinical quality and member outcomes
Participate in peer review activities, including Quality of Care and Quality of Service evaluations
Provide clinical leadership during interdisciplinary rounds and support evidence-based standards of care
Promote evidence-based practice and standardized clinical approaches that support high-quality care
Engage network providers to address care gaps, support quality improvement, and encourage evidence-based practice
Build strong relationships with provider organizations, health systems, and community partners to support quality, utilization, and member experience goals
Work closely with the Wisconsin Department of Health Services (DHS), including close collaboration with the DHS Chief Medical Officer and the Chief Medical Officers of other Wisconsin Medicaid HMO Plans on statewide quality and performance initiatives
Apply knowledge of Wisconsin DHS and ForwardHealth requirements and applicable state and federal Medicaid regulations to support compliant clinical operations
Support implementation of policy and process changes that enhance clinical programs and operations
Help reduce unwarranted variation in care through provider education, engagement, and best practices
Partner with the Chief Executive Officer and plan leadership to help advance clinical strategies aligned with market, regulatory, and organizational priorities
Support development and execution of care models that improve outcomes and member experience
Mentor and support clinical and operational colleagues to encourage growth, collaboration, and strong performance
Help foster a culture of accountability, collaboration, and continuous improvement
Bring clinical insight into care management, population health, and quality improvement initiatives
Contribute to strategic planning, program development, and operational priorities