Director OF Utilization Management

Medical DirectorOptum 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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization 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. as you take on some tough challenges.Primary Responsibilities:Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinationsDocument clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirementsEngage with requesting providers as needed in peer-to-peer discussionsBe knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviewsParticipate in daily clinical rounds as requestedCommunicate 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 policyCommunicate and collaborate with other internal partnersParticipate in holiday and call coverage rotationYou'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 American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)Active unrestricted license to practice medicine5+ years of clinical practice experience after completing residency trainingSound understanding of Evidence Based Medicine (EBM)Proven solid PC skills, specifically using MS Word, Outlook, and ExcelProven ability and willingness to participate in rotational holiday and call coveragePreferred Qualifications:Licensed in Massachusetts desirableBoard certification in Internal Medicine or Family MedicationExperience in utilization and clinical coverage reviewProven data analysis and interpretation aptitudeProven innovative problem-solving skillsPay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $248,500 - $373,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. 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.UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.