Sign up to access all features of our service.
  • Job search
  • Favorites
  • Create a CV
    New
  • Salaries
  • Subscriptions

Medical Director, Claims & Utilization Review

Texas Health Institute

UnitedHealth Group is seeking a Medical Director to provide physician support for Enterprise Clinical Services. The role focuses on clinical knowledge applied to benefit coverage determinations and cost-efficient, high-quality care. You will work with network and non-network physicians to ensure timely and accurate determinations. Requirements include an MD or DO with an active license, board certification in Medicine, and 5+ years of post-residency clinical experience. #J-18808-Ljbffr Texas Health Institute

Vacancy posted 2 days ago
Similar jobs that could be interesting for youBased on the Medical Director, Claims & Utilization Review in Brooklyn, NY vacancy
  • $248.5k - $373k

     ...as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and...  ...manage health care costs. The Medical Director provides physician support to Enterprise...  ...of clinical knowledge in various utilization management activities with a focus on... 
    Claims
    Remote job
    Minimum wage
    Full time
    Work experience placement
    Local area

    RXinsider LTD.

    Brooklyn, NY
    2 days ago
  • Integra Partners seeks an experienced Utilization Review Medical Director to lead clinical reviews of DMEPOS requests within a remote UM environment. You will ensure decisions meet Medicare/Medicaid guidelines and internal policies while maintaining timely throughput and... 
    Suggested
    Remote job

    Integra Partners

    Brooklyn, NY
    1 day ago
  • Integra Partners, a national DMEPOS network administrator, seeks a remote Utilization Review Medical Director. You will conduct clinical reviews of DMEPOS requests, ensure determinations meet Medicare/Medicaid guidelines, and maintain high-quality documentation in a fast... 
    Suggested
    Remote job
    Full time

    Remote Genie

    Brooklyn, NY
    5 days ago
  • Hawaii Medical Service Association is seeking a Concurrent Nurse Reviewer for the Facility Utilization Review Unit. The role requires applying clinical...  ...stays and suspended claims for HMSA members. Under minimal...  ...coordinate with medical directors, case management, and other... 
    Claims

    Hawaii Medical Service Association

    Brooklyn, NY
    4 days ago
  •  ...BlueCross BlueShield South Carolina subsidiary, seeks a Medical Reviewer II (RN) to perform medical claim reviews and determine medical necessity using...  ...guidelines. The role documents decisions and supports utilization review across multiple services. The position is remote... 
    Claims
    Remote job
    Full time

    Southcarolinablues

    Brooklyn, NY
    3 days ago
  • UnitedHealth Group's Optum unit seeks a Medical Director to lead the Focus Claims Review program, overseeing medical services, provider discussions, and policy development. This role emphasizes quality and coordination across reviews. You can work remotely from anywhere... 
    Claims
    Remote job

    ISHE

    Brooklyn, NY
    2 days ago
  • $68k - $133k

     ...middle of the pay range Oversight of the nurse review teams that conducts medical necessity review as part of HMSA Utilization Management program that includes prior authorization, payment determination, post-service claim reviews, QI specific programs, out-of-network... 
    Claims
    Work experience placement
    Work at office

    Hawaii Medical Service Association

    Brooklyn, NY
    3 days ago
  • Optum seeks a Medical Director to provide physician support for Enterprise Clinical Services, focusing on post-service benefit determinations and medical necessity decisions. You will lead clinical reviews, collaborate with hospital networks, and contribute to cost-effective... 
    Claims
    Remote job

    Colorado Psychiatric

    Brooklyn, NY
    2 days ago
  • Optum, a global health services company, seeks a Medical Director to lead the Focus Claims Review team. You will oversee medical claim review quality, coordinate with physicians and other providers, and set policies and clinical criteria for medical programs and services... 
    Claims
    Remote job

    Rhode Island Bar Assn.

    Brooklyn, NY
    2 days ago
  • $88.85k

     ...and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented,... 
    Claims
    Full time

    L.A. Care Health Plan

    Brooklyn, NY
    5 days ago
  • The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent...  ...out-patient treatment, certifies the medical necessity and assigns an appropriate...  ...communicates issues of concern to the appropriate claims staff/customer Collects data and... 
    Claims
    Minimum wage
    Work at office
    Local area
    Remote work
    Flexible hours

    CorVel Corporation

    Brooklyn, NY
    3 days ago
  • Job Description Join Hilo Benioff Medical Center and be part of a team that proudly cares...  ...Professional Nurse III to support our Utilization Review and Appeals functions. This role is...  ...progress. Assist with appeals of denied claims by analyzing records, identifying discrepancies... 
    Claims
    Full time
    Shift work
    Weekend work

    US Lawns

    Brooklyn, NY
    2 days ago
  •  ...hours are required to address utilization review cases. Roles and...  ...monitoring of cases involving medical decisions and quality of care...  ...certification, reimbursement, and claim denials/appeals. Employ active...  ...relationship with Medical Director on CM and UM cases.... 
    Claims
    Live in
    Remote work
    Flexible hours
    Weekday work

    Evry Healthcare Inc.

    Brooklyn, NY
    1 day ago
  • ## Utilization Review NurseApplyremote type: Hybridlocations: 1301 6th Ave W - BRADENTON, FLposted...  ...requirements. This role reviews medical information submitted by treating providers...  ...with physicians, healthcare providers, claims professionals, and internal team members... 
    Claims
    Work at office
    Immediate start
    Remote work
    Flexible hours
    2 days per week

    Acrisure, LLC

    Brooklyn, NY
    4 days ago
  • $71.1k - $97.8k

    Become a part of our caring community The Utilization Management Nurse 2 uses clinical...  ...coordination, documentation and communication of medical services or benefit administration...  ...of experience in prior authorization, claims review, utilization management, or other healthcare... 
    Claims
    Full time
    Temporary work
    Apprenticeship
    Work at office
    Remote work
    Work from home
    Home office
    Monday to Friday

    Humana Inc

    Brooklyn, NY
    4 days ago
  •  ...implementation of strategies that promote medical management, practice...  ...management programs (e.g., utilization, prior authorization, case...  ...assigned area/s (e.g., utilization review/quality assurance, case...  ...predetermination reviews and reviews of claim determinations, providing... 
    Claims
    Private practice
    Live in
    Remote work

    Nebraska Blue

    Brooklyn, NY
    5 days ago
  • $236.5k

     ...clinical professional on our Medical Management/Health...  ...leadership of all for utilization management, cost...  ...activities. Performs medical review activities pertaining...  ...Assists Chief Medical Director in planning and...  ...care quality. Reviews claims involving complex, controversial... 
    Claims
    Remote job
    Full time
    Part time
    Work at office
    Flexible hours
    Weekend work

    Centene Corporation

    Brooklyn, NY
    4 days ago
  • $210k - $260k

     ...program by determining the medical appropriateness of services by reviewing clinical information and...  ...to the Managing Medical Director for Cohere Health, this...  ...-based criteria while utilizing clinical acumen and knowledge...  ...data with post‑service claims validation, we’re... 
    Claims
    Remote job
    Flexible hours

    Cohere Health

    Brooklyn, NY
    1 day ago
  • $200k - $270k

     ...Primary Responsibilities The Medical Director (MD) reports directly to the...  ...provide independent medical review where required by law, rule,...  ...medical expertise for utilization management and care management...  ...data from medical and pharmacy claims and medical record reviews to... 
    Claims
    Contract work
    For contractors
    Weekend work
    Afternoon shift

    State of Vermont

    Brooklyn, NY
    1 day ago
  • UnitedHealth Group seeks a Medical Director to lead clinical coverage reviews and benefit determinations within Enterprise Clinical Services. You will collaborate...  ...knowledge, communication, and remediation of utilization management. You can work remotely from anywhere in... 
    Remote job

    ISHE

    Brooklyn, NY
    2 days ago
  • Sacbar is seeking a Medical Director of Prior Authorization and Utilization Management in Palm Springs, CA. The role focuses on prior authorization, concurrent review, and utilization management with a flexible hybrid remote arrangement. The position offers a competitive... 
    Remote work
    Relocation package
    Flexible hours

    Sacbar

    Brooklyn, NY
    2 days ago
  • WellMed, part of the Optum family, is seeking a Medical Director for Utilization Management to support utilization determinations and identify trends...  ...current with CMS criteria, and participating in case reviews and medical necessity determinations. Qualified candidates... 
    Remote job

    Sacbar

    Brooklyn, NY
    5 days ago
  • $54k - $103k

     ...direction, conducts on-site Claim audits of Auto Physical Damage...  ...levels of customer service. Reviews and makes recommendations regarding...  ...Claims Quality Review Director Skills, Knowledge & Abilities...  ...a sense of urgency; able to utilize and manage all available resources... 
    Claims
    Work experience placement
    Work at office
    Local area

    CNA

    Brooklyn, NY
    4 days ago
  • UnitedHealth Group in Minnesota seeks a Medical Director to provide physician support for...  ...determinations and medical necessity reviews. The role partners with a multidisciplinary...  ...effective, high-quality care, advances utilization management, and communicates policies... 
    Remote job

    Texas Health Institute

    Brooklyn, NY
    2 days ago
  •  ...senior auditing RN to perform retrospective chart reviews on Readmission and Place of Service Claims, applying clinical guidelines and considering claims...  ...auditing systems. The ideal candidate has 5-7+ years in Utilization/Case Management with an ICU/CCU background, and... 
    Claims
    Remote job

    Cotiviti

    Brooklyn, NY
    4 days ago
  •  ...FL, is seeking a Physician Advisor to educate and advise Utilization Management, HIM, Revenue Cycle, Patient Access, and managed...  ...and denial prevention. The role provides physician-level review of utilization, claims management, and quality assurance for inpatient,... 
    Claims

    AdventHealth

    Brooklyn, NY
    3 days ago
  •  ...Blue Shield of Mississippi seeks an RN Medical Reviewer, FEP to perform thorough clinical reviews...  ...pre-service requests and post-service claims for medical and medical drug services....  ...document decisions clearly, and monitor utilization trends for potential Care Management... 
    Claims

    Bcbsms

    Brooklyn, NY
    2 days ago
  • UnitedHealth Group is seeking a Medical Director to lead the Focus Claims Review program. This role oversees medical services coordination, provider discussions, and policy development related to medical claim reviews. In addition, you may assist in directing clinical... 
    Claims
    Remote job

    UnitedHealth Group

    Brooklyn, NY
    2 days ago
  • Optum, a part of UnitedHealth Group, seeks a Medical Director to provide physician support for Enterprise Clinical Services. You will lead clinical reviews for benefit determinations, collaborate with leadership to implement processes, and ensure high-quality, cost-effective... 
    Claims

    ISHE

    Brooklyn, NY
    2 days ago
  • UnitedHealth Group is seeking a Medical Director to lead the Focus Claims Review program, ensuring quality and coordination of medical services for claims reviews. The role involves provider discussions, appeals, and policy guidance, with remote work flexibility across... 
    Claims
    Remote job

    Texas Health Institute

    Brooklyn, NY
    2 days ago

Do you want to receive more vacancies?

Subscribe and receive similar vacancies to Medical Director, Claims & Utilization Review. Be the first to apply!