Medical Director jobs at CareFirst BlueCross BlueShield - 82 jobs

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**Medical Principal Job Description** ** Primarily regional with national level case work for Cigna Healthcare (CHC) -- Cigna. **Summary description of position** : A Medical Principal performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers. He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry to mid-level position for a physician interested in a career in health care administration. **Major responsibilities and required results:** + Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles. + Works to achieve quality outcomes for customers/members with a focus on service and cost + Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills. + Balances customer/member needs with business needs while serving as a customer/member advocate at all times. + Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations + Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees. + Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects + Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes. + Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information and the fostering of positive collegial relationships. + Demonstrates knowledge as a peer reviewer by applying current evidence-based guidelines, including novel treatments, to support high-quality clinical decision-making across medical and behavioral health conditions, diseases, treatments, and procedures. Medical directors are required to maintain and update their knowledge base through monthly focused updates of Cigna's comprehensive evidence-based coverage policies, as well as through mandatory inter-rater reliability testing, continuing medical education, and maintenance of board certification. + Addresses customer service issues with mentoring and support from leadership staff. + Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff. + Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions. + Provides clinical insight and management support to other functional areas and matrix partners as needed or directed. **Minimum Requirements:** + Current unrestricted medical license in a US state or territory. + Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty + Exhibits ethical and professional behavior. + Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency + Computer Competency: Word processing, Spreadsheet, Email, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired. + Must not be excluded from participation in any federal health care program** + Must not be included in CMS' Preclusion List** **Preferred Skill Sets:** + Experience in medical management, utilization review and case management in a managed care setting. + Knowledge of managed care products and strategies. + Ability to work within changing business environment and balance patient advocacy with business needs. + Experience with managing multiple projects in a fast-paced matrix environment. + Demonstrated ability to educate colleagues and staff members. + Successful experience and comfort with change management. + Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills. + Successful ability to assess complex issues, to determine and implement solutions, and resolve problems. + Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders. + Demonstrated sensitivity to culturally diverse situations, participants, and customers/members. + Service marketing, sales, and business acumen experience a plus. + Fluency in Spanish (Cigna Medicare) or other languages If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 206,300 - 343,900 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus and long term incentive plan. We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group . **About The Cigna Group** Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we're dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives. _Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws._ _If you require reasonable accommodation in completing the online application process, please email:_ _*********************_ _for support. Do not email_ _*********************_ _for an update on your application or to provide your resume as you will not receive a response._ _The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State._ _Qualified applicants with criminal histories will be considered for employment in a manner_ _consistent with all federal, state and local ordinances._

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees. May be required to work weekends and holidays in support of business operations, as needed. Education/Experience: Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. License/Certifications: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. Current Indiana state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $221,300.00 - $420,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Lead a team of medical directors and supervises MD's responsible for utilization management and appeals functions to ensure members receive medically necessary, evidence-based care aligned with bet practice promoting safety, quality and cost of care outcomes. Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit in collaboration with Operations, Health plan leaders and cross functional stakeholders across the enterprise Provide medical leadership for all utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities. Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assist the VPMA in the functioning of the physician committees including committee structure, processes, and membership. Oversee the activities of physician advisors and other medical directors. Utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participate in provider network development and new market expansion as appropriate. Assist in the development and implementation of physician education with respect to clinical issues and policies. Identify utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice by profiling providers in order to improve the quality and cost of care. Interface with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Review claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. May develop alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represent the business unit at appropriate state committees and other ad hoc committees. May oversee all aspects of the Appeals and Denials department including implementing budgetary, policy, and personnel decisions for the department. Work flexible hours to ensure adequate staffing levels and coverage, including weekends and holidays, to meet patient care needs and support case coverage. Performs other duties as assigned Complies with all policies and standards Education/Experience: Medical Doctor or Doctor of Osteopathy. 7+ years of clinical experience in the practice of medicine. Advanced degree in health care management, informatics preferred but not required Management experience, 5 years or more of leading large physician teams in a matrixed environment, preferred. Utilization Management experience and knowledge of quality accreditation standards preferred. Experience analyzing and working with complex data sets and knowledge of population health preferred Experience treating or managing care for a culturally diverse population preferred. License/Certification: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. We're Hiring: Full time Medical Directors in New York! Centene Corporation is a leading provider of government-sponsored healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the Health Insurance Marketplace. Looking for a compelling opportunity to move beyond patient encounters and drive meaningful change in the community? Qualifications for this role include: MD or DO without restrictions Must be licensed in New York Board certified in Internal Medicine or Family Medicine preferred Utilization Management experience and knowledge of quality accreditation standards. Actively practices medicine Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees. May be required to work weekends and holidays in support of business operations, as needed. Performs other duties as assigned Complies with all policies and standards Education/Experience: Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. License/Certifications: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. (Certification in Psychiatry specialty Is required.) Current New York state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Lead a team of medical directors and supervise MD's responsible for utilization management and appeals functions to ensure members receive medically necessary, evidence-based care aligned with bet practice promoting safety, quality and cost of care outcomes. Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit in collaboration with Operations, Health plan leaders and cross functional stakeholders across the enterprise. Provide medical leadership for all utilization management (appeals), pharmacy, case management, disease management, cost containment, and medical quality improvement activities. Develop and have oversight of training and expertise for Medicare appeals reviews, ALJ hearings. Have oversight of STARS metrics related to appeals and collaborate with key stakeholders for IRE challenges Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assist the VPMA in the functioning of the physician committees including committee structure, processes, and membership. Oversee the activities of physician advisors and other medical directors. Utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participate in provider network development and new market expansion as appropriate. Assist in the development and implementation of physician education with respect to clinical issues and policies. Identify utilization review studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice by profiling providers in order to improve the quality and cost of care. Interface with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Review claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. May develop alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represent the business unit at appropriate state committees and other ad hoc committees. May oversee all aspects of the Appeals and Denials department including implementing budgetary, policy, and personnel decisions for the department. Work flexible hours to ensure adequate staffing levels and coverage, including weekends and holidays, to meet patient care needs and support case coverage. Performs other duties as assigned Complies with all policies and standards Education/Experience: Medical Doctor or Doctor of Osteopathy. 7+ years of clinical experience in the practice of medicine. Advanced degree in health care management, informatics preferred but not required Management experience, 5 years or more of leading large physician teams in a matrixed environment, preferred. Deep knowledge of Medicare policies and procedures (Manuals, NCD's, LCD's, final rules, STARS metrics) and previous experience leading Medicare Appeals, IRE and ALJ hearings, STARS metrics Previous experience with ensuring high quality medical director training to review Medicare UM and appeals, Clinical review quality oversight and management. Utilization Management experience and knowledge of quality accreditation standards preferred. Experience analyzing and working with complex data sets and knowledge of population health preferred Experience treating or managing care for a culturally diverse population preferred. License/Certification: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. We are hiring a Medical Director for our New Jersey market. The ideal candidate will reside within a commutable distance of our New Jersey office. Centene Corporation is a leading provider of government-sponsored healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the Health Insurance Marketplace. Looking for a compelling opportunity to move beyond patient encounters and drive meaningful change in the community? Qualifications for this role include: MD or DO without restrictions Must be licensed in New Jersey Board certified in Family Medicine or Internal Medicine or Emergency Medicine Utilization Management experience and knowledge of quality accreditation standards highly preferred Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees. May be required to work weekends and holidays in support of business operations, as needed. Performs other duties as assigned Complies with all policies and standards Education/Experience: Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. License/Certifications: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. (Certification in Psychiatry specialty Is required.) Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $210,800.00 - $400,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. We're Hiring: Full time Medical Director in North Carolina. Centene Corporation is a leading provider of government-sponsored healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the Health Insurance Marketplace. Looking for a compelling opportunity to move beyond patient encounters and drive meaningful change in the community? Qualifications for this role include: MD or DO without restrictions Must be licensed AND reside in North Carolina American Board Certification Utilization Management experience and knowledge of quality accreditation standards highly preferred Position Purpose: Supports health plan operations through medical management, quality improvement and/or credentialing functions for the business unit Provides medical insights and/or interpretation for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for network providers. May assist Chief Medical Office in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. May participate in the functioning of the physician committees including committee structure, processes, and membership. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies and shares trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. May participate in clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in the context of regular reviews of utilization and/or health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community that support development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees. Education/Experience: Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. License/Certifications: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. Current North Carolina state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $210,800.00 - $400,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. + Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. + Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. + Supports effective implementation of performance improvement initiatives for capitated providers. + Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. + Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. + Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. + Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. + Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. + Participates in provider network development and new market expansion as appropriate. + Assists in the development and implementation of physician education with respect to clinical issues and policies. + Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. + Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. + Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. + Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. + Develops alliances with the provider community through the development and implementation of the medical management programs. + As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. + Represents the business unit at appropriate state committees and other ad hoc committees. + May be required to work weekends and holidays in support of business operations, as needed. **Education/Experience:** + Medical Doctor or Doctor of Osteopathy. + Utilization Management experience and knowledge of quality accreditation standards preferred. + Actively practices medicine. + Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. + Experience treating or managing care for a culturally diverse population preferred. **License/Certifications:** + Active Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. + Active American Board Certification in Internal and Family Medicine, is preferred + Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Job Responsibilities Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines. Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives. Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews. Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST. Willingness to travel within the State of Tennessee and nationally. Job Qualifications Education Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. *However, this requirement can be waived for jobs where the totality of the incumbents duties and responsibilities are restricted to the performance of administrative duties only. Based on business need, an unencumbered and unrestricted license in an alternative state may be substituted. Experience 5 years - Clinical experience required 5 years - Healthcare administration and/or UM experience preferred Skills\Certifications Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists Ability to conceive and deliver innovative solutions Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability. Outstanding negotiation, presentation, and facilitation skills Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint) Ability to interpret and explain complex government policies Knowledge of Medicare programs Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver's license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). *The definition for "routine basis" is defined as daily, weekly or at regularly schedule times. Number of Openings Available 0 Worker Type: Consultant Company: BCBST BlueCross BlueShield of Tennessee, Inc. Applying for this job indicates your acknowledgement and understanding of the following statements: BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page: BCBST's EEO Policies/Notices BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Dane Street is looking for an Associate Medical Director to serve the needs of one of our larger clients. Availability for conversation with client Medical Directors, assisting in auditing cases where necessary, and reviewing areas of dispute in more complex cases. The successful candidate will have multiple state licenses, past Medical Director experience, understand Workers' Compensation laws throughout the US, and know various state Workers' Compensation treatment guidelines. Candidates must be able to perform exams under Washington rules, must be licensed in Washington, and approved by Labor and Industries. This is a part-time position, not likely to require more than 10 hours per month. Dane Street's success relies on individual and team contributions every day. We care for our customers, each other and Dane Street. It is the responsibility for all of us to maintain a positive working environment that promotes client satisfaction and results. Requirements EDUCATION/CREDENTIALS: A Medical Degree from a recognized university and board certification in a specialty. Must be approved by Labor & Industries JOB RELEVANT EXPERIENCE: Business experience in a healthcare and/or insurance setting is preferred. Must be able to perform exams under Washington rules. Must be licensed in Washington. JOB RELATED SKILLS/COMPETENCIES: Present exceptional communication skills with a clear understanding of company business lines. The ability to apply critical thinking, manage time efficiently, and meet specific deadlines. Computer literacy and typing skills are essential. WORKING CONDITIONS/PHYSICAL DEMANDS: Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work. WORK FROM HOME TECHNICAL REQUIREMENTS: Supply and support their own internet services. Maintaining an uninterrupted internet connection is a requirement of all work from home position. This job description is subject to change at any time.

✨Join a group of passionate advocates on our mission to improve the lives of at-risk youth! Rite of Passage Team is hiring for a Medical Director - Child & Adolescent Psychiatry at Childhelp, Alice C. Tyler Village in Lignum, Virginia✨ Childhelp is a psychiatric residential treatment facility that specializes in the treatment of children aged 5-14 with mild to severe trauma or neglect, psychiatric disorders, and neurodevelopmental disorders. Our unique location on a 270-acre farm provides a nurturing treatment setting with a variety of therapy resources. We bring the light of love and healing into the lives of countless abused and neglected children, and those suffering from psychiatric and behavioral disorders. We take a holistic approach to serving our children along with meeting their physical, emotional and educational needs. Becoming a member of our Childhelp team is more than a job, it's an opportunity to create a meaningful career with a mission driven organization. Pay: To be determined based on Education and Experience. $200,000-$350,000 Perks & Benefits: Medical, Dental, Vision and company paid Life Insurance within 90 days, and 401k match of up to 6% after 1 year of employment, Paid Time Off that can be used as soon as it accrues and more! ROP-benefits-and-perks-2 What you will do: The Medical Director works as a member of the Student Services team. Primarily responsible to ensure that the health and welfare of the students is maintained. Provides mental health care including diagnosis, psychiatric evaluations and testing, and medication management to the children in residential placement. The Psychiatric Medical Authority reports to the Program Director and supervises work performed by contracted Psychiatic Mental Health Nurse Practitioners or other contracted Psychiatrists. To be considered you should: Medical Doctor/Physician License to practice in the state of Virginia ~ Possess a current and valid certification ~ Have related experience working with at-risk youth ages 5-14 ~ Prior expereince with child mental heatlh conditions and treatment ~ Be able to pass a criminal background check, drug screen, physical, and TB test. Schedule: Monday through Friday Apply today and Make a Difference in the Lives of Youth! After 40 years of improving the lives of youth, we are looking for passionate advocates to continue the legacy of helping young people become successful adults. As a Medical Director - Child & Adolescent Psychiatry , you will have the unique opportunity to create a positive, safe and supportive environment for the youth we serve while building a career rich in growth opportunities and self-fulfillment. Follow us on Social! Instagram / Facebook / Linkedin / Tik Tok / YouTube

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start **Caring. Connecting. Growing together.** Here at Optum, we have an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs. The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical Services. The Medical Director collaborates with Enterprise Clinical Services leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on post-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 Enterprise Clinical Services. The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member's primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that the appropriate and most cost effective quality medical care is provided to members. If you reside in Florida, you will have the flexibility to work remotely* as you take on some tough challenges. **Primary Responsibilities:** + 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 You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Doctor of Medicine or Osteopathy + Current active, unrestricted license to practice as a physician without restrictions in the state of FL + Current board certification in Internal Medicine or Family Practice + 5+ years of clinical practice experience after completing residency training + Substantial experience in using electronic clinical systems + Solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices + PC skills, specifically using MS Word, Outlook, and Excel + Ability to participate in rotational weekend and holiday call coverage + Currently reside in Florida **Preferred Qualifications:** + Hands-on experience in utilization review + Clinical practice experience in the last 2 years + Data analysis experience + Data analysis and interpretation experience and skills + Sound knowledge of the managed care industry + Proven excellent presentation skills for both clinical and non-clinical audiences *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 - $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. **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. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start **Caring. Connecting. Growing together** . Responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company. The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for Pain Management procedures ( e.g. spinal chord stimulators, pain pumps, nerve ablations, facet injections, etc.) + Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers) + Works with clinical staff to coordinate all the necessary UM processes and provides feedback to staff who do portions of the UM reviews + Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable + Discusses cases and clinical situations with treating providers telephonically during scheduled hours + Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews + Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews + Participate in rotational call coverage. Is available for occasional, periodic weekend and holiday as needed telephonic and remote computer expedited clinical decisions + Provide Clinical support for staff that conduct initial reviews + Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current, active, and fully unrestricted medical license + Current Board Certification and must maintain pain subspecialty with specialty in either PM&R or Anesthesia + 5+ years clinical experience post residency in Pain subspecialty + Proficient with MS Office (MS Word, Email, Excel, and Power Point) + Excellent computer skills and ability to learn new systems and software + Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel + Participate in rotational call coverage + Must be willing and able to obtain additional medical licenses as needed **Preferred Qualifications:** + License in North Carolina or New Mexico a plus + Experience in managed care UM activities + Must possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments + Experience with integration of clinical and financial data, development of utilization and performance reporting tools, and communication of performance data to physicians and other health care providers *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience, and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. **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. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Optum Radiation Oncology Medical Director will provide clinical guidance to help implement a next-generation comprehensive Radiation Oncology solution which will successfully meet clinical, quality, and financial performance objectives. This solution will help ensure providers deliver high-quality, evidence-based and cost-efficient radiation oncology care for our clients. As such, this role requires an innovative, hands-on, action-oriented clinician. This position will serve as a member of the radiation oncology team dedicated to helping ensure high levels of quality, affordability, and member and provider satisfaction. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * Perform utilization review determinations for radiation oncology populations, and support case and disease management teams to achieve optimal clinical outcomes * Speak with providers by phone. This will include discussion of evidence-based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expense * Enhance clinical expertise of the radiation oncology team through education sessions with nursing teams, and serving as a thought leader and point of contact for relevant medical societies & stakeholders * Deliver the Optum clinical value proposition focused on quality, affordability and service, in support of the sales and growth activities including conducting client presentations and participating in customer consultations * Evaluate clinical and other data (e.g., quality metrics, claims & health record data, utilization data) to identify opportunities for improvement of clinical care and processes * Collaborate with operational and business partners on enterprise-wide research, clinical and quality initiatives to enhance Optum impact in the Radiation oncology field * This remote-work position will require the use of a company provided personal computer, internet access and familiarity with Microsoft Office applications * Rotational weekend/ holiday on-call coverage as scheduled You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * MD or DO with an active, unrestricted medical license * Current board certification in Radiation Oncology * 5+ years of clinical practice experience (inclusive of radiation oncology) * Proficiency with Microsoft Office applications * Demonstrated accomplishments in the areas of medical care delivery systems, utilization management, case management, disease management, quality management, product development and/or peer review * Proven ability to quickly gain credibility, influence and partner with staff and the clinical community * Participate in rotational weekend/ holiday on-call coverage as scheduled Preferred Qualifications: * Experience in managed care, quality management or administrative leadership * Experience working with payer guidelines * Experience in client-facing customer relationship management * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 - $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. 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. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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. Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company. The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. The focus of the coverage reviews will be various types of musculoskeletal surgical procedures and other medical/surgical services for musculoskeletal procedures including therapy * Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers) * Works with clinical staff to coordinate all the necessary coverage reviews and provides feedback to staff who do portions of the coverage reviews * 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 * Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews * 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 * Call coverage rotation. Is available for periodic weekend and holiday coverage as needed for telephonic and remote computer expedited clinical decisions * Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable * Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * MD or DO with an active, unrestricted medical license * Current, active and unrestricted medical license * Willing to obtain additional licenses as needed * Board Certification in Orthopedic Surgery * 5+ years clinical practice experience post residency * Sound understanding of Evidence Based Medicine (EBM) * Proficient with MS Office (MS Word, Email, Excel, and Power Point) * Proven excellent computer skills and ability to learn new systems and software * Proven excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel Preferred Qualifications: * 2+ years managed care, Quality Management experience and/or administrative leadership experience * Experience in utilization and clinical coverage review * Clinical experience within the past 2 years * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $269,500 to $425,500 annually based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization 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. 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), with a focus on outpatient pharmacy reviews, and on communication regarding this process with both network and non-network physicians, as well as other UnitedHealth Group departments. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 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 * 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 * Ability to obtain additional state medical licenses as needed * Participate in rotational weekend and holiday call coverage * Other duties and goals assigned by the medical director's supervisor You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Active, unrestricted physician license * Current board certification in Gastroenterology * 5+ years of clinical practice experience in Gastroenterology after completing residency training * Substantial experience in using electronic clinical systems * Ability to participate in rotational weekend and holiday call coverage * Solid belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices * PC skills, specifically using MS Word, Outlook, and Excel Preferred Qualifications: * Hands-on experience in utilization review * Clinical practice experience in the last 2 years * Sound knowledge of the managed care industry * Data analysis and interpretation experience and skills * Excellent presentation skills for both clinical and non-clinical audiences * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy. Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. 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. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs. The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical Services. The Medical Director collaborates with Enterprise Clinical Services leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. 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 Enterprise Clinical Services. The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member's primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that the appropriate and most cost-effective quality medical care is provided to members. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * 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 * 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 * Call coverage rotation You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * M.D or D.O * Active unrestricted license to practice medicine * Board certification approved by the American Board of Medical Specialties (ABMS) * 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 Preferred Qualifications: * Current licensure in Hawaii, California, Washington, Arizona, Oregon or Nevada * Willing to obtain additional licensure if needed * Board Certification in Internal Medicine, Family Practice, Surgery, Plastic Surgery but other board certifications considered * Experience in utilization and clinical coverage review * Proven data analysis and interpretation aptitude * Proven innovative problem-solving skills * Demonstrated excellent presentation skills for both clinical and non-clinical audiences * Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skills * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 - $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. 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. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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. Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company. The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for spine surgery * Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers) * Works with clinical staff to coordinate all the necessary coverage reviews and provides feedback to staff who do portions of the coverage reviews * 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 * Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews * 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 * Call coverage rotation. Is available for periodic weekend and holiday coverage as needed for telephonic and remote computer expedited clinical decisions * Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable * Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Current, active and unrestricted medical license * Current Board Certification in Orthopedic Surgery or Neurosurgery * 5+ years clinical experience post residency in Orthopedic Surgery or Neurosurgery to include experience with musculoskeletal/ spine surgery * Sound understanding of Evidence Based Medicine (EBM) * Proficient with MS Office (MS Word, Email, Excel, and Power Point) * Excellent computer skills and ability to learn new systems and software * Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel * Willing to obtain additional licenses as needed Preferred Qualifications: * Active license in South Carolina, Minnesota or Texas, but candidates with an active license in other states are acceptable * ABMS or other nationally recognized further specialized certifications * Experience in managed care UM activities/ coverage reviews * Possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments * Experience with integration of clinical and financial data, development of utilization and performance reporting tools, and communication of performance data to physicians and other health care providers No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. 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. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.