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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:

Medical and Clinical Operations



Approximate Salary:

Not Specified

Position Type:

Full Time

Medical Claim Review Medical Director - Virtual

UHG - Houston, Texas

Posted: 11/17/2018

What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere.

United Employer & Individual Medical Claim Review Medical Director

The Medical Director provides physician support to Medical Claim Review (MCR) operations, the organizations responsible for the initial (MCR) post service clinical review of claims for UnitedHealth Group (UHG). The Medical Director collaborates with MCR leadership and staff to establish, implement, support and maintain clinical and operational processes related to both benefit coverage determinations and reimbursement policy decisions. The Medical Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on post-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 UnitedHealth Group departments.

Job responsibilities:

o Conduct coverage review based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in peer-to-peer telephone calls.
o Use clinical knowledge in the application and interpretation of UHG medical policy and benefit document language in the process of clinical coverage review for UnitedHealth Group.
o Use clinical knowledge in the application and interpretation of specific UHG reimbursement policies.
o Conduct daily clinical review and evaluation of all service requests collaboratively with MCR nursing staff.
o Provide support for MCR nurses and non-clinical staff in multiple sites in a manner conducive to teamwork.
o Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants; educates providers on benefit plans and UHG medical policy.
o Communicate with and assist Medical Directors outside MCR regarding coverage and other pertinent issues.
o Communicate and collaborate with other departments such as the preservice Clinical Coverage Review team and Inpatient Concurrent Review team regarding coverage and other issues.
o Be available and accessible to the MCR staff throughout the day to respond to inquiries. Serve as a clinical resource, coach and leader within MCR.
o Document clinical review findings, actions and outcomes in accordance with MCR policies, and regulatory and accreditation requirements.
o Actively participate as a key member of the MCR teams in regular meetings and projects focused on communication, feedback, problem solving, process improvement, staff training and evaluation and sharing of program results.
o Actively participate in identifying and resolving problems and collaborate in process improvements that may be outside own team.
o Provide clinical and strategic leadership when participating on national committees and task forces focused on achieving MCR goals.
o Other duties and goals assigned by the medical director's supervisor.

• Active, unrestricted physician license. REQUIRED
• Current board certification in ABMS or AOBMS specialty. REQUIRED
• 5+ years of clinical practice experience. REQUIRED
• Solid PC skills, specifically using MS Word, Outlook, and Excel. REQUIRED. Experience in other MS programs a plus.
• Excellent telephonic and interpersonal communication skills.
• Team player and strong teambuilding skills.
• Hands-on experience in utilization and coverage review in a health plan with commercial membership. PREFERRED
• Substantial experience in using electronic clinical systems in the provider or payer setting. PREFERRED
• Strong belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices.
• Sound knowledge of the managed care industry.
• Creative problem solving skills.
• Data analysis and interpretation experience and skills. Project management background a plus.
• Excellent presentation skills for both clinical and non-clinical audiences.
• Supervisory skills, including clinical mentoring and coaching expertise.

Transforming health care and millions of lives starts with the values you embrace and the passion you bring. Find out more and join us. It's an opportunity to do your life's best work.SM

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.SM

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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