1+ months

Clinical Medical Director- San Juan, PR

Blanding, UT 84511
  • Job Code

Looking for a chance to drive measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability? You can make a difference at UnitedHealth Group and our family of businesses in serving our Medicare, Medicaid and commercial members and plan sponsors. Be part of changing the way health care is delivered while working with a Fortune 6 industry leader.

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 UnitedHealthcareare 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




Posted: 2019-11-01 Expires: 2020-02-29

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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Clinical Medical Director- San Juan, PR

UnitedHealth Group
Blanding, UT 84511

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