UnitedHealth Group
Medical Director Clinical Coverage Review - Pharmacy - Remote
UnitedHealth Group, Boise, Idaho, United States, 83708
UnitedHealth Group Medical Director Clinical Coverage Review - Pharmacy - Remote Boise, Idaho
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity 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.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; educates providers on benefit plans and UHC medical policy.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.Provide clinical and strategic leadership when participating on national committees and task forces focused on achieving Clinical Coverage Review goals.Participate in rotational call coverage as needed.Other duties and goals assigned by the medical director's supervisor.Required Qualifications:Current board certification in ABMS or AOA specialty.5+ years of clinical practice experience after completing residency training.Substantial experience in using electronic clinical systems.Proven solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices.PC skills, specifically using MS Word, Outlook, and Excel.Excellent presentation skills for both clinical and non-clinical audiences.Excellent telephonic and interpersonal communication skills.Team player and teambuilding skills.Preferred Qualifications:Reside in PST or MST.Hands-on experience in utilization review.Clinical practice experience in the last 2 years.Data analysis experience.Sound knowledge of the managed care industry.Project management background.Proven problem solving expertise.Supervisory skills, including clinical mentoring and coaching expertise.*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington or Washington, D.C. Residents Only:
The salary range for this role is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).Application Deadline:
This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
#J-18808-Ljbffr
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity 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.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; educates providers on benefit plans and UHC medical policy.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.Provide clinical and strategic leadership when participating on national committees and task forces focused on achieving Clinical Coverage Review goals.Participate in rotational call coverage as needed.Other duties and goals assigned by the medical director's supervisor.Required Qualifications:Current board certification in ABMS or AOA specialty.5+ years of clinical practice experience after completing residency training.Substantial experience in using electronic clinical systems.Proven solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices.PC skills, specifically using MS Word, Outlook, and Excel.Excellent presentation skills for both clinical and non-clinical audiences.Excellent telephonic and interpersonal communication skills.Team player and teambuilding skills.Preferred Qualifications:Reside in PST or MST.Hands-on experience in utilization review.Clinical practice experience in the last 2 years.Data analysis experience.Sound knowledge of the managed care industry.Project management background.Proven problem solving expertise.Supervisory skills, including clinical mentoring and coaching expertise.*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington or Washington, D.C. Residents Only:
The salary range for this role is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).Application Deadline:
This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
#J-18808-Ljbffr