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Medical Claim Review Medical Director - Virtual

UnitedHealth Group

Dallas, TX
Job Code:
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Job Details

Medical Claim Review Medical Director - Virtual(Job Number:705637)

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.

Job Clinical Analysis & Consulting
Primary Location US-TX-Dallas
Other Location US-NY-New York, US-FL-Tampa, US-AZ-Phoenix, US-IL-Chicago, US-CA-Los Angeles
Organization CCR/Prior Authorization/MCR
Schedule Full-time
Number of Openings 2
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UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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