Medical Director, UM - Therapy Reviews - Remote - UnitedHealth Group

Optum 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company.

The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations.

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 determinations. The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services for musculoskeletal procedures including therapy.
• Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers).
• Works with clinical staff to coordinate all the necessary coverage reviews and provides feedback to staff who do portions of the coverage reviews.
• 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.
• Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews.
• 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. Is available for periodic weekend and holiday coverage as needed for telephonic and remote computer expedited clinical decisions.
• Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable.
• Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations.

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