Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)
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.
If you live in the state of Texas, you’ll enjoy the flexibility to telecommute* as you take on some tough challenges.
- 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.
- Call coverage rotation
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.
- M.D or D.O.
- Board certification approved by the American Board of Medical Specialties (ABMS)
- Active unrestricted license to practice medicine
- At least five 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
- Current license in TX
- Previous experience in utilization and clinical coverage review
- Excellent oral, written, and interpersonal communication skills, facilitation skills
- Data analysis and interpretation aptitude
- Innovative problem-solving skills
- Excellent presentation skills for both clinical and non-clinical audiences
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy
UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.
Job Keywords: Medical Director, Texas, Telecommute, Board Certified, M.D, D.O, Clinical Advocacy & Support