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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 Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

The Medical Director’s work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand processes with a focus on collaborative business relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support value throughout all activities.

Primary Responsibilities:

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, policies, clinical standards, and (in some cases) contracts. The ideal candidate supports and collaborates with other team members and other doctors. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines.

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

• Engage with requesting providers as needed in peer-to-peer discussions

• 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

• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• M.D, D.O., or M.B.B.S

• Current and ongoing Board Certification an approved MCI Medical Specialty

• 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment

• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health

• Solid PC skills, specifically using MS Word, Outlook, and Excel

• Proven excellent verbal and written communication skills

Preferred Qualifications:

• Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance

• Experience with national guidelines such as MCG or InterQual

• Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists

• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health

• Proven curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals

• Proven to participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution

• Proven to be passionate about contributing to an organization’s focus on consistency in outcomes, consumer experiences and a highly engaged team culture

• Proven ability to identify medical management operational improvements, including those within the medical director area

• Proven to develop collaborative relationships with Team and key partners within the Line of Business

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.