At UnitedHealthcare, were simplifying the health care experience, creating healthier communities and removing barriers to quality care.
The work you do here impacts the lives of millions of people for the better.
Come build the health care system of tomorrow, making it more responsive, affordable and equitable.
Ready to make a difference?
Join us and start doing your life’s best work.(sm) The National Senior Medical Director will report to the CMO of the UHC Individual and Family Plans (IFP) and is a key member of the IFP Clinical Leadership Team.
The IFP National Senior Medical Director will work with IFP national clinical leaders to develop and execute clinical strategies to improve our compliance, quality performance, affordability, and clinical outcomes across 22 states.
The position will have joint accountability for clinical excellence for our IFP membership, clinical benefit design, new clinical program implementations and process improvements, monitoring and valuing clinical outcomes and operational performance, clinically evaluating affordability opportunities, supporting the development and implementation of initiatives to meet quality standards, and ensuring compliance with federal and state regulatory requirements.
This individual will partner with Optum clinical leaders and market CMOs to drive resolution of complex member cases/member and provider escalations and implementation of critical clinical initiatives to ensure we deliver the best possible member and provider experience and clinical outcomes for over 500,000 members while managing business performance.
This critical leadership role will collaborate across the UHG clinical organization, partnering with Shared Services teams such as Optum Enterprise Clinical Services, Optum Behavioral Health, Optum Medical Benefit Management, and Optum Population Health Services leaders to drive continuous improvement and increased efficiencies of IFP utilization management, prior authorization, and care management programs across all markets.
The National Senior Medical Director will also partner with the IFP Product team on the design of state-specific clinical benefits that align with EHB state benchmarks and state mandates and with United Clinical Services team on the development of medical policies and prior authorization lists for new markets.
This individual will work in a highly matrix organization and will be responsible for impacting results and change without direct authority.
In addition, this position will partner with the IFP Quality team to support the development of quality improvement and population health initiatives to meet HEDIS quality standards and optimize star ratings and support the achievement and maintenance of NCQA Health Plan accreditation for all IFP health plans.
The National Senior Medical Director has a significant role in distinguishing our Individual and Family Plan business in the marketplace by driving clinical outcomes, supporting sustainable care, and fueling differentiated growth.
Youll enjoy the flexibility to work remotely from anywhere within the U.S.
as you take on some tough challenges.
Primary Responsibilities: Clinical Excellence Provide oversight of performance from cross-enterprise matrixed clinical teams Identify opportunities to continuously improve / update the IFP clinical model for competitiveness, compliance, efficiency, and affordability Identify innovation opportunities and develop new clinical programs and initiatives that improve quality and clinical outcomes for IFP members, increase the effectiveness of the IFP clinical model, and drive clinical efficiencies for the IFP business Ensure continuously developing efficiencies in delivering clinical model by Shared Services teams (including Optum Enterprise Clinical Services, Optum Behavioral Health, Optum Medical Benefit Management, and Optum Population Health Services) Provide strategic clinical leadership to support key clinical staff and programs throughout the IFP business Conduct quarterly deep dive review of clinical programs with Shared Services teams to assure clinical model effectiveness Provide guidance for clinical operational aspects of the IFP business and serves as a clinical resource and consultant to other areas of the business Represent IFP business on UHG clinical committees (including the Medical Technology Assessment Committee, Coverage Determination Guideline Committee, Formulary Trend Management, IFP Pharmacy Management Committee, and National Medical Care Management Committee) Complex Member Cases/Clinical Escalations Support clinical stakeholders and work closely with the IFP VP of Clinical Transformation and Operations to investigate and drive resolutions to member and provider escalations from market CEOs and CMOs, regulator/DOI complaints, and other key internal and external stakeholders Ensure timely and consistent responses to all escalations/complaints and the best clinical outcomes for members Partner with clinical leaders from Shared Services teams including Optum Enterprise Clinical Services, Optum Behavioral Health, and Optum Population Health Services to establish member centered IFP Clinical Interdisciplinary Rounds to discuss complex IFP members and ensure alignment across teams to support our members interdisciplinary needs Design, Execute and Monitor Clinical Programs Jointly with Shared Services Teams Partner with Shared Services teams (including Optum Enterprise Clinical Services, Optum Behavioral Health, Optum Medical Benefit Management, and Optum Population Health Services) to improve our prior authorization, inpatient utilization management, and care management programs by identifying areas of opportunity and executing on initiatives to address these opportunities Engage with Shared Services teams to drive development of new clinical strategies, programs, and processes Evaluate existing processes and identify opportunities for continuous improvement of these processes to improve our members and providers experience Provide requirements and oversee development and deployment of new strategies and programs and implementation of process improvements On a periodic basis, report progress towards affordability and quality targets along with our Shared Services partners and describe pathways for improvement Regularly evaluate program outcomes, quality, affordability, and operational results with shared set of metrics and hold Shared Services Teams accountable Clinical Benefit Design and Medical Policy Partner with the IFP Product team on the design of state-specific clinical benefits in the Certificates of Coverage filed in each state that align with EHB state benchmarks and state mandates Partner with United Clinical Services team on the development of medical policies, prior authorization lists, and Pay Code Status Files for new markets Partner with the IFP Product and United Clinical Services teams on updated to market-specific clinical benefits, medical policies, prior authorization lists, and Pay Code Status Files for existing markets based on new state and federal mandates, competitor analysis, and UHG initiatives Provide IFP clinical and business feedback to the United Clinical Services team to ensure alignment of medical policies, prior authorization lists, and Pay Code Status files with IFP clinical benefits in the Certificate of Coverage filed in each market Monitor health care policy, medical research, and competitive landscapes for emerging medical policy opportunities Affordability Partner with Medical Economics and IFP Affordability teams to evaluate trend and identify opportunities to address key drivers of utilization and costs Monitor health care policy, medical research, and competitive landscapes for emerging affordability opportunities Provide clinical feedback on potential affordability and member experience improvement opportunities Quality Performance Ensure services are delivered to members at the highest quality standards Partner with IFP VP of Clinical Quality and Health Equity and IFP Quality Team on the development of quality improvement and population health initiatives to meet HEDIS quality standards and optimize star ratings Support achievement and maintenance of NCQA Health Plan accreditation for all health plans by providing oversight of Health Plan accreditation activities including the Quality Improvement, Utilization Management, and Network Adequacy standards Act as an improvement catalyst for quality improvement efforts including partnering with Optum Behavioral Health to improve behavioral health related quality measure performance and the IFP Pharmacy team to enhance medication adherence rates Compliance Partner closely with the IFP Director of Clinical Compliance to ensure that IFP clinical staff comply with all state and federal rules and regulations Oversee and ensure compliance with federal and state compliance standards around prior authorization, utilization review, and appeals and grievances through working with and holding accountable Compliance, Clinical Services, Optum, and other clinical delegates Conduct comprehensive reviews of cases referred for Quality of Care concerns.If substandard care is identified, develop Improvement Action Plan to address substandard care and minimize chance for future occurrence Youll 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 Board Certified in anABMS or AOBMS specialty 5 years clinical practice experience; solid knowledge of managed care industry Experience managing utilization management, prior authorization, and care management programs for a Managed Care company Solid understanding of HEDIS quality measurement and experience developing quality improvement programs and initiatives Ability to successfully work in a matrix management environment, with a proven track record of building and maintaining effective internal partnerships that lead to external client satisfaction Solid understanding of compliance related issues and understanding of state contractual obligations Full COVID-19 vaccination is an essential job function of this role.
Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements.
UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance.
Candidates must be able to perform all essential job functions with or without reasonable accommodation Preferred Qualifications Individual & Family Plan experience, will also consider Medicaid or other commercial health plan experience Exceptional Relationship skills.
Proven ability to quickly build and maintain strong relationships across diverse functions and leaders Solid strategic thinking and business acumen with the ability to align strategies and recommendations with clinical operations objectives.
Adaptable and flexible style of collaborating with key stakeholders in setting direction Proven ability to quickly gain credibility, influence and partner with business leaders and the clinical operations community Ability to lead and motivate people to achieve agreed-upon results, with a focus on driving disciplined, fact-based decisions and executing with discipline and urgency Solid attention to detail, particularly in taking large amounts of data and making decisions based on relevant data Expectations Deliver value to members by optimizing the member experience and clinical outcomes while maximizing member growth and retention Lead and influence employees by fostering teamwork and collaboration, driving employee engagement, and leveraging diversity and inclusion Communicate and present effectively, listen actively and attentively to others, and convey genuine interest Influence and negotiate effectively to arrive at win-win solutions Demonstrate pro-active, solution-oriented approaches to work efforts and drive disciplined, fact-based decisions Execute with discipline and urgency and drive improvements: Drive exceptional performance; deliver value to the customer; closely monitor execution; drive operational excellence; get directly involved when needed; balance speed with analysis; ensure accountability for results Drive change and innovation though continually seeking and implementing novel solutions; create a culture that thrives on continuous change; inspire people to stretch beyond their comfort zone; take well-reasoned risk; challenge ‘the way it has always been done’; change direction as required Lead change and innovation by demonstrating emotional resilience, managing change by proactively communicating the case for change and promoting a culture that thrives on change.
Play an active role in implementing innovative solutions by challenging the status quo and encouraging others to do so Model and demand integrity and compliance with all company policies, and local, state, and federal regulations To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment.
In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function.
UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance.
Candidates must be able to perform all essential job functions with or without reasonable accommodation.
Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment Careers at UnitedHealthcare Community & State.
Challenge brings out the best in us.
It also attracts the best.
That’s why you’ll find some of the most amazingly talented people in health care here.
We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy.
Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors.
Join us.
Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most.
This is the place to do your life’s best work.(sm) California, Colorado, Connecticut, Nevada, Washington or New York City Residents Only: The salary range for California, Colorado, Connecticut, Nevada, Washington or New York City residents is $363,459 to $574,956.
Salary Range is defined as total cash compensation at target.
The actual range and pay mix of base and bonus is variable based upon experience and metric achievement.
Pay is based on several factors including but not limited to education, work experience, certifications, etc.
In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
No matter where or when you begin a career with UnitedHealth Group, youll find a far-reaching choice of benefits and incentives.
All employees working remotely will be required to adhere to UnitedHealth Groups Telecommuter Policy At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone.
We believe everyoneof every race, gender, sexuality, age, location and incomedeserves 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.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug
– free workplace.
Candidates are required to pass a drug test before beginning employment.
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