Utilization Management Medical Director- Remote

About the Role

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The Medical Director provides physician support to Enterprise Clinical Services operations, responsible for the initial clinical review of service requests. This role 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 Medical Director's activities focus on applying clinical knowledge in utilization management, particularly pre-service benefit and coverage determinations (medical necessity according to the benefit package), and communicating these processes with network and non-network physicians. You'll collaborate with a multidisciplinary team and engage with members' primary care providers or specialists to ensure appropriate, cost-effective, and quality medical care.

You'll enjoy the flexibility to work remotely from anywhere within the U.S.

Responsibilities

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies; render coverage determinations.
• Document clinical review findings, actions, and outcomes in accordance with policies, regulatory, and accreditation requirements.
• Engage with requesting providers in peer-to-peer discussions as needed.
• 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 ensure accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy.
• Collaborate with other internal partners.
• Participate in holiday and call coverage rotation.

Requirements

• M.D. or D.O. degree.
• Board certification by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
• Active unrestricted license to practice medicine.
• 5+ years of clinical practice experience after completing residency training.
• Sound understanding of Evidence-Based Medicine (EBM).
• Proven proficiency with MS Word, Outlook, and Excel.
• Willingness to participate in rotational holiday and call coverage.

Preferred Qualifications

• Licensed in Massachusetts.
• Board certification in Internal Medicine or Family Medicine.
• Experience in utilization and clinical coverage review.
• Proven data analysis and interpretation aptitude.
• Proven innovative problem-solving skills.

Benefits

In addition to your salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The salary for this role ranges from $248,500 to $373,000 annually based on full-time employment. Pay is determined by several factors, including local labor markets, education, work experience, and certifications.