Medical Claims Review, Medical Director - Remote
UnitedHealth Group
- Houston, TX
- Permanent
- Full-time
- Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
- 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
- Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
- Participate in daily clinical rounds as requested
- 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
- M.D. or D.O.
- Board certification approved by the American Board of Medical Specialties (ABMS)
- Active unrestricted license to practice medicine
- 5+ years of clinical practice experience after completing residency training
- Sound understanding of Evidence Based Medicine (EBM)
- Proven solid PC skills, specifically using MS Word, Outlook, and Excel
- Board certification in Internal Medicine or Family Medicine
- Experience in utilization and clinical coverage review
- Proven data analysis and interpretation aptitude
- Proven innovative problem solving skills
- Proven excellent presentation skills for both clinical and non-clinical audiences
- Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skill