Medical Director

Medical Director, Clinical AI Innovation And PerformanceAt UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.UnitedHealthcare is leveraging AI, real-time data and a modern platform to modernize clinical programs - starting with Utilization Management. The Medical Director, Clinical AI Innovation and Performance is a senior physician leader responsible for the clinical AI model training, testing and surveillance. Work will initially focus on utilization management (UM) clinical criteria-leveraging InterQual, UHC custom specialty content and other evidence-based criteria. The MD will establish efficient and consistent annotation, training and testing models to ensure medical policies are accurately interpreted, evidence based, consistently applied, and operationally effective.This role serves as the clinical authority for guideline interpretation, clarification, and enhancement, ensuring that approved medical policy and supporting evidence are translated into UM clinical criteria that enable appropriate coverage decisions, support safe and effective care, and scale across enterprise operations. The initial focus will be on Prior Authorization and will expand to include Inpatient Level of Care. Clinical Care Management and Comprehensive Medication Management.The clinical annotation, training and testing team will report to this physician. The MD will be the primary clinical relationship to Foundation model clinical teams (Antrhopic, OpenAI, Gemini). The CMO will work closely with the CMO Medical Policy, the CMO Value Creation, the CMO of Medical Management and the MD, Data Science. MD will also be a key member of the UCS clinical and AI leadership team, collaborating on clinical program design, data models, AI use and modernization.You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.Primary Responsibilities:InterQual Expertise, Interpretation & Guideline Enhancement Maintain deep expertise in InterQual criteria, evidence framework, and decision logicEnsure consistent, accurate interpretation of InterQual criteria across: Services, settings, and levels of careReviewer types and UM workflowsLead guideline clarification, customization, and enhancement where needed to: Improve clinical clarity and consistencyAddress operational ambiguity or recurring edge casesEnhance the ability to ensure care is safe and effectiveDevelop and approve evidence based enhancements or supplemental criteria that add clinical clarity while remaining aligned with approved medical policyWork closely with leaders in Medical Policy and evidence teams to ensure: Alignment with policy intentClear translation of policy into UM ready clinical criteriaEvidence Based UM Clinical Criteria Ensure UM clinical criteria are: Explicitly grounded in clinical evidence and accepted guidelinesStructured for consistent application at scaleClear and actionable for nurses, physician reviewers, and AI enabled workflowsApply senior clinical judgment in situations where: Evidence is evolving or limitedCriteria require interpretation to ensure appropriate coverage decisionsPromote consistent clinical standards across UM operations while recognizing the need for appropriate clinical flexibilityUM Operations & Coverage Interpretation Leadership Ensure UM criteria function effectively in production environments: Supporting timely and appropriate coverage decisionsReducing unwarranted variation across reviewersAligning clinical interpretation with operational realityPartner closely with UM Operations and Nursing leadership to: Identify areas of confusion or friction in criteria applicationAddress recurring themes from operational feedbackImprove reviewer confidence and consistencyClinical Annotation & LLM Training for UM Lead teams responsible for clinical annotation and analysis supporting LLM based UM decision supportOversee the clinical review process that ensures: Accurate interpretation of UM criteria by LLMsReliable assessment of whether clinical documentation meets criteriaProvide clinical oversight and judgment where: Annotator disagreement existsCriteria vary in complexity or trainabilityAdditional training data or clarification is requiredEnsure annotation and training processes support clinically accurate, reliable model performanceAI Lifecycle Participation & Governance (UCS Led) Serve as a senior physician leader within UCS led AI governance, under the authority of the UHC CMOParticipate in reviews across AI lifecycle phases: Training and validationShadow modeAI assist (clinical in the loop)Production deploymentContribute clinical judgment to evaluations of: Precision and recallClinical accuracy and safetyReadiness for use in automated approvalsIdentify areas where additional training, refinement, or safeguards are requiredCross Functional Clinical Leadership & Continuous Improvement Directly manage: Clinical annotatorsClinical or UM analysts supporting AI enablement and criteria oversightWork closely with: Medical Policy leadershipCARES team conducting rigorous UM case review and quality evaluationUM Operations and AppealsProduct, ECS, and AI / data science teamsEnsure insights from production, appeals, audits, and quality reviews inform: Guideline clarification and enhancementReviewer guidanceOngoing improvement of AI model performance and safetyYou'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:MD or DO with active/unrestricted U.S. Medical LicensureBoard certification in an ABMS/AOBMS Clinical specialtySignificant experience in: Utilization managementCoverage interpretation using UM clinical criteriaClinical operations in large, complex organizationsDemonstrated experience working with InterQual clinical criteriaExperience with UM physicians and nursing teams at scaleProven ability to lead through influence across clinical, operational, and technical teamsPreferred Qualifications:Experience across Commercial and/or Government program UMExperience working with MCG guidelinesProven direct responsibility for UM operations leadershipProven exposure to AI enabled clinical workflows or advanced decision support (technical expertise not required)Leadership Profile (Senior Leadership Team Level)Recognized clinical authority with strong peer credibilityDemonstrated judgment in complex or ambiguous clinical scenariosAble to operate at enterprise scale while maintaining clinical rigor