Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. Our team directly improves health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. We foster a culture guided by inclusion, talented peers and 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.
Clinical Advocacy & Support focuses on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. In this role, you will empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver a seamless experience, and manage healthcare costs.
The Medical Director provides physician support to Enterprise Clinical Services operations, which is responsible for the initial clinical review of service requests. The Medical Director collaborates with leadership and staff to establish, implement, support, and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost-effectiveness of services for members. The role primarily applies clinical knowledge to utilization management activities with a focus on pre‑service benefit and coverage determination or medical necessity, and on communicating this process with both network and non‑network physicians and other Enterprise Clinical Services.
You will collaborate with a multidisciplinary team and be actively involved in the management of medical benefits for all lines of business, often involving member primary care or specialist physicians. Your primary responsibility is to ensure that the appropriate and most cost‑effective, high‑quality medical care is provided to members.
You'll enjoy the flexibility to work remotely from anywhere within the U.S. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week. Working in the Pacific Time Zone is preferred.
Primary Responsibilities
- Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, and render coverage determinations.
- Document clinical review findings, actions, and outcomes in accordance with policies, regulatory and accreditation requirements.
- Engage with requesting providers as needed in peer‑to‑peer discussions.
- Interpret existing benefit language and policies during clinical coverage reviews.
- Participate in daily clinical rounds as requested.
- Communicate and collaborate with network and non‑network providers to achieve accurate and timely benefit determinations, while educating providers about benefit plans and medical policy.
- Communicate and collaborate with other internal partners.
- Call coverage rotation.
Required Qualifications
- M.D. or D.O.
- Active unrestricted license to practice medicine.
- Board certification in Physical Medicine & Rehabilitation, Internal Medicine, or Family Medicine.
- 5+ years of clinical practice experience after completing residency training.
- Sound understanding of Evidence Based Medicine (EBM).
- Proven PC skills, specifically using MS Word, Outlook, and Excel.
Preferred Qualifications
- Multiple state licenses.
- Experience in utilization and clinical coverage review.
- Data analysis and interpretation aptitude.
- Innovative problem‑solving skills.
- Excellent oral, written, and interpersonal communication skills, including facilitation.
- Excellent presentation skills for both clinical and non‑clinical audiences.
- Residence in the Pacific Time Zone.
- All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
Compensation for this specialty generally ranges from $269,500 to $425,500. Total cash compensation includes base pay and bonus and is based on several factors including local labor markets, education, work experience, and may increase over time based on productivity and performance. We comply with all minimum wage laws as applicable. In addition to salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and a 401(k) contribution (subject to eligibility requirements).
Application Deadline: This posting will be available for a minimum of 2 business days or until a sufficient candidate pool has been collected. The job posting may close early due to volume of applicants.
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.
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