Medical Claims Review, Medical Director - Remote

Company: UnitedHealth Group
Location: San Jose
Posted on: November 16, 2023

Job Description:

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. -

Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs. -

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 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. 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., preferably in Texas as you take on some tough challenges.

Primary Responsibilities:

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• 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
  
  
  You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:
  
  • 
    
  • M.D or D.O.
    
  • Board certification approved by the American Board of Medical Specialties (ABMS)
    
  • Active unrestricted license to practice medicine
    
  • 5+ years of clinical practice experience after completing residency training
    
  • Sound understanding of Evidence Based Medicine (EBM)
    
  • Solid PC skills, specifically using MS Word, Outlook, and Excel
    
    
    Preferred Qualifications:
    
    • 
      
    • Experience in utilization and clinical coverage review
      
    • Proven data analysis and interpretation aptitude
      
    • Proven innovative problem solving skills
      
    • Proven excellent presentation skills for both clinical and non-clinical audiences
      
    • Proven excellent oral, written, and interpersonal communication skills, facilitation skill
      
      
      California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is -$248,582 to -$338,965 per year. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. -
      
      *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy -
      
      At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. -
      
      
      Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. -
      
      UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment -

Keywords: UnitedHealth Group, San Jose , Medical Claims Review, Medical Director - Remote, Executive , San Jose, California