Medical Claims Review Medical Director – Remote (USA)
Location: Remote, United States (Primary Location: Eden Prairie, MN)
Job Category: Medical and Clinical Operations
Requisition Number: 2333473
Employment Type: Full-Time
Overview
Optum, a part of UnitedHealth Group, is a global healthcare organization focused on improving health outcomes through technology-enabled care delivery, pharmacy benefit management, and data-driven clinical services. The organization supports millions of individuals by connecting them to quality healthcare resources, evidence-based medicine, and cost-effective benefit solutions.
The Medical Claims Review Medical Director plays a critical leadership role within Enterprise Clinical Services. This position is responsible for physician-level oversight of medical claims review, utilization management, and post-service benefit determinations. The role is fully remote within the United States and is ideal for experienced physicians seeking to transition into a clinical operations, payer-side medical review, or healthcare leadership career path.
Role Summary
The Medical Director provides clinical expertise in reviewing service requests, determining medical necessity, and ensuring benefit coverage aligns with established policies and member plan documents. This role collaborates with internal clinical teams, healthcare providers, and operational leadership to ensure accurate, compliant, and cost-effective healthcare decisions.
The position requires strong knowledge of evidence-based medicine, benefit interpretation, regulatory compliance, and utilization review processes. The Medical Director ensures that quality standards are upheld while maintaining efficiency and consistency in medical claims adjudication.
Key Responsibilities
Conduct medical necessity and coverage reviews based on individual member benefit plans and national or proprietary clinical policies.
Render benefit coverage determinations in accordance with regulatory, accreditation, and internal compliance standards.
Document clinical findings, decisions, and outcomes accurately within established systems and guidelines.
Participate in peer-to-peer discussions with requesting physicians when required to clarify clinical rationale.
Interpret and apply benefit language and medical policies during the clinical review process.
Collaborate with multidisciplinary teams to support quality improvement initiatives and cost management strategies.
Engage in daily clinical rounds or case consultations as requested.
Communicate effectively with network and non-network providers to ensure timely and accurate benefit determinations.
Required Qualifications
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
Active and unrestricted license to practice medicine in the United States.
Board Certification in Family Medicine, Internal Medicine, or Emergency Medicine.
Minimum 5+ years of post-residency clinical practice experience.
Demonstrated expertise in Evidence-Based Medicine (EBM).
Proficiency in Microsoft Office applications including Word, Outlook, and Excel.
Preferred Qualifications
Active medical license in Texas or California.
Interstate Medical Licensure Compact participation.
Prior experience in utilization review, medical claims review, or payer-side clinical operations.
Strong analytical and data interpretation skills.
Proven problem-solving and decision-making capabilities.
Excellent written, verbal, and interpersonal communication skills.
Residence within Pacific Standard Time (PST) or Mountain Standard Time (MST) preferred.
Work Environment
This is a remote position within the United States. All remote employees must comply with the organization’s telecommuting policies and operational standards.
Compensation and Benefits
The compensation range for this role is approximately USD 248,500 to 373,000 annually, including base salary and performance-based incentives. Final compensation is determined by experience, education, geographic market, and productivity metrics.
The comprehensive benefits package may include medical, dental, and vision coverage, retirement savings plans with employer contributions, equity stock purchase options, incentive programs, and professional development opportunities. Eligibility criteria apply.
Application Timeline
The position will remain open for a minimum of two business days or until a sufficient candidate pool has been identified. The listing may close earlier based on application volume.
Equal Opportunity Commitment
UnitedHealth Group is committed to advancing health equity and reducing disparities in healthcare access and outcomes. The organization supports inclusive hiring practices and promotes diversity across race, gender, age, geographic location, and socioeconomic backgrounds.
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Siliguri |Illinois :
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Tallinn |Hà Nội :
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Niš |Bohemia :
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