The Clinical Medical Director provides physician support to a variety of processes, including Clinical Coverage Review (CCR) and/or Sub-acute, Post-acute concurrent review for patients receiving care in subacute, skilled or long-term care facilities.

Specifically, for the Clinical Coverage Review role, the Clinical Medical Director provides physician support to Clinical Coverage Review (CCR) operations, the organization responsible for the initial clinical review of service requests for UnitedHealthcare (UHC). The Medical Director collaborates with CCR leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit coverage determinations. The Clinical 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), and on communication regarding this process with both network and non-network physicians, as well as other UnitedHealthcare are departments.

The Clinical Medical Director role supporting sub-acute and post-acute concurrent, utilization review is responsible for assessing patient disease states and treatment in accordance with evidence-based guidelines, resource and care coordination, and interpretation of clinical reports and ensuring compliance with Federal, State, and Local regulatory and organizational guidelines.

Specifically, these physicians will be reviewing the care for members that are in a post-acute setting. This includes Long Term Acute Rehab, Skilled Nursing Facilities and Acute Inpatient Rehabilitation Facilities. They will be responsible for determinations, against Milliman Care Guidelines (MCG) and clinical experience for admission and ongoing concurrent review when patients do not meet guidelines, as outlined by MCG or UnitedHealthcare’s policy.

Primary Responsibilities:

• 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
• Use clinical knowledge in the application and interpretation of UHC medical policy and benefit document language in the process of clinical coverage review for UnitedHealthcare
• Conduct daily clinical review and evaluation of all service requests collaboratively with Clinical Coverage Review and other staff
• Provide support for nurses 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 immediate department 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 departmental staff throughout the day to respond to inquiries. Serve as a clinical resource, coach and leader within CCR and affiliated business departments
• Access clinical specialty panel to assist or obtain assistance in complex or difficult cases and support care coordination
• Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements
• Actively participate as a key member of the assigned 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 and other specific business goals
• Other duties and goals assigned by the medical director's supervisor

*** ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***

Required Qualifications:

• Active, unrestricted US physician license
• Current board certification in ABMS or AOA specialty.
• 5+ years of clinical practice experience after completing residency training.
• 5+ years hands-on experience in utilization and clinical coverage review in a health plan setting
• Substantial experience in using electronic clinical systems in the payer setting.
• Knowledge of the managed care industry.
• Solid PC skills, specifically using MS Word, Outlook, and Excel. Experience in other MS programs a plus.
• Data analysis and interpretation experience and skills.
• English Proficiency

Preferred Qualifications:

• Board certification in Family/General Practice
• Experience working with a Commercial membership.
• Demonstrated practice in accordance with EBM (Evidence Based Medicine), and familiarity with current medical issues and practices.
• Supervisory skills, including clinical mentoring and coaching
• Project management background

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

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.

Job Keywords: Medical Director, MD, Medical Clinical Review, Clinical Coverage, San Juan, PR