Clinical Coverage Review Medical Director
The Medical Director provides physician support 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 CCR leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit 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), and on communication regarding this process with both network and non-network physicians, as well as other UnitedHealth Care departments.
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 UnitedHealth Care.
Conduct daily clinical review and evaluation of all service requests collaboratively with Clinical Coverage Review staff.
Provide support for CCR 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 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.
Is 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 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 goals.
Other duties and goals assigned by the medical director's supervisor.
Active, unrestricted 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 coverage review in a health plan with Commercial membership.
Substantial experience in using electronic clinical systems in the payer setting.
Sound knowledge of the managed care industry.
Strong belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices.
Solid PC skills, specifically using MS Word, Outlook, and Excel. Experience in other MS programs a plus.
Supervisory skills, including clinical mentoring and coaching expertise preferred
Data analysis and interpretation experience and skills. Project management background a plus.
Excellent telephonic and interpersonal communication skills.
Team player and strong teambuilding skills.
Creative problem solving skills.
Excellent presentation skills for both clinical and non-clinical audiences.
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