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Medical Director Clinical Coverage Review

4 months ago

Saint Louis, United States Optum Full time
Job Description

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. 

 

The Clinical Coverage Review Medical Director is a key member of the Optum Enterprise Clinical Services Team. On the Focused Pharmacy Review team, they are responsible for providing physician support to Optum Rx Pharmacy Team, and to Clinical Coverage Review (CCR) operations, the organization responsible for the initial clinical review of service requests for UnitedHealth Care (UHC). The Medical Director collaborates with Optum Rx and CCR leadership and staff to establish, implement, support, and maintain clinical and operational processes related to outpatient pharmacy and medical coverage determinations. 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), with a focus on outpatient pharmacy reviews, and on communication regarding this process with both network and non-network physicians, as well as other UnitedHealth Group departments.

 

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 

 

Primary Responsibilities: 

  • Review and sign off on proposed pharmacist denials for preservice outpatient medication requests, after review of medical records when provided

  • Conduct coverage review on some medical cases, 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.

  • Use clinical knowledge in the application and interpretation of medical and pharmacy policy and benefit document language in the process of clinical coverage review’s guidelines.

  • Conduct daily clinical review and evaluation of all service requests collaboratively with Clinical Coverage Review staff.

  • Provide support for CCR nurses, pharmacists, and non-clinical staff in multiple sites in a manner conducive to teamwork.

  • 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 UHC medical policy.

  • Communicate with and assist Medical Directors outside CCR regarding coverage and other pertinent issues.

  • Communicate and collaborate with other departments such as the Inpatient Concurrent Review team regarding coverage and other issues.

  • Is available and accessible to the CCR staff throughout the day to respond to inquiries. Serve as a clinical resource, coach, and leader within CCR.

  • Access clinical specialty panel to assist or obtain assistance in complex or difficult cases.

  • Document clinical review findings, actions, and outcomes in accordance with CCR policies, and regulatory and accreditation requirements.

  • Actively participate as a key member of the CCR team in regular meetings and projects focused on communication, feedback, problem solving, process improvement, staff training and evaluation and sharing of program results.

  • Actively participate in identifying and resolving problems and collaborates in process improvements that may be outside own team.

  • Provide clinical and strategic leadership when participating on national committees and task forces focused on achieving Clinical Coverage Review goals.

  • Ability to obtain additional state medical licenses as needed

  • Participate in rotational call coverage as needed (one weekend

  • Other duties and goals assigned by the medical director's supervisor

 

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 as well as provide development for other roles you may be interested in. 

Required Qualifications:

  • Active, unrestricted physician license

  • Current board certification in ABMS or AOA specialty

  • 5+ years of clinical practice experience after completing residency training

  • Substantial experience in using electronic clinical systems

  • Proven ability to participate in rotational call coverage

  • Proven solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices

  • Proven solid PC skills, specifically using MS Word, Outlook, and Excel

  • Proven excellent presentation skills for both clinical and non-clinical audiences

  • Proven excellent telephonic and interpersonal communication skills

  • Proven team player and teambuilding skills

  • Proven creative problem solving skills

 

Preferred Qualifications:

  • Clinical practice experience in the last 2 years

  • Hands-on experience in utilization review

  • Data analysis experience

  • Project management background

  • Problem Solving expertise

  • Sound knowledge of the managed care industry

  • Proven supervisory skills, including clinical mentoring and coaching expertise

  • Proven data analysis and interpretation experience and skills 

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

 

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

 

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 believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. 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.   

 

 

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.