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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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization 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. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.
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; educate 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
Be 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 collaborate 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
Obtain additional state medical licenses as needed
Participate in rotational weekend and holiday call coverage
Other duties and goals assigned by the medical director's supervisor
Required Qualifications:
Active, unrestricted physician license
Current board certification in Rheumatology, Hematology‑Oncology, Internal Medicine, Family Practice or Emergency Medicine
5+ years of clinical practice experience after completing residency training
Substantial experience in using electronic clinical systems
Proven ability to participate in rotational weekend and holiday call coverage
Proven solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices
Proficient PC skills, specifically using MS Word, Outlook, and Excel
Preferred Qualifications:
Clinical practice experience in the last 2 years
Hands‑on experience in utilization review
Data analysis experience
Sound knowledge of the managed care industry
Proven data analysis and interpretation experience and skills
Proven excellent presentation skills for both clinical and non‑clinical audiences
Reside in PST or MST
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401(k) contribution (all benefits are subject to eligibility requirements).
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug‑free workplace. Candidates are required to pass a drug test before beginning employment.
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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. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.
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; educate 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
Be 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 collaborate 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
Obtain additional state medical licenses as needed
Participate in rotational weekend and holiday call coverage
Other duties and goals assigned by the medical director's supervisor
Required Qualifications:
Active, unrestricted physician license
Current board certification in Rheumatology, Hematology‑Oncology, Internal Medicine, Family Practice or Emergency Medicine
5+ years of clinical practice experience after completing residency training
Substantial experience in using electronic clinical systems
Proven ability to participate in rotational weekend and holiday call coverage
Proven solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices
Proficient PC skills, specifically using MS Word, Outlook, and Excel
Preferred Qualifications:
Clinical practice experience in the last 2 years
Hands‑on experience in utilization review
Data analysis experience
Sound knowledge of the managed care industry
Proven data analysis and interpretation experience and skills
Proven excellent presentation skills for both clinical and non‑clinical audiences
Reside in PST or MST
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401(k) contribution (all benefits are subject to eligibility requirements).
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug‑free workplace. Candidates are required to pass a drug test before beginning employment.
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