Chief Medical Officer – UCS Clinical Assessment Review Expert

At UnitedHealthcare, we’re 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 to start Caring. Connecting. Growing together.

The Chief Medical Officer of United Clinical Services Clinical (UCS) Assessment Review is a critical role to ensure the UnitedHealthcare national clinical programs successfully meet clinical, quality, growth, and financial performance objectives.  This role requires a visionary, innovative, hands-on clinical and operational business leader with an executive presence who is client savvy and who will thrive when challenged with the opportunity to optimize clinical program value, specific to all Utilizations Management (UM) related-activities that are sponsored by the Lines of Businesses.  This executive will report directly to the Chief Medical Officer, Medical Management and serve as a key business unit partner dedicated to leveraging clinical assets to help UHC achieve maximum value through high levels of quality, compliance, affordability, client, patient, and provider satisfaction performance.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Serve as an executive leader within the Medical Management with accountability over the CARES team, including executive strategic vision and accountability of all key operations
• Manage a team of nurses, and a medical director responsible for monitoring ECS and other Optum Program clinical, affordability, and operational outcomes
• Provide strategic leadership in collaboration with operations, Medical Management pillar leads, Healthcare Economics – medical informatics, finance, and other key matrixed Line of Business partners through all phases of relevant UM programs, including Inpatient Concurrent Review, Prior Authorization, and Medical Claims Review as distinct examples
• Work in partnership with enterprise operational, LOB partners, and Value Creation leadership to address gaps & deficiencies for existing clinical programs, as well as helping to inform clinical value for future medical management initiatives
• Support the business in identifying clinical trends and supporting strategy
• Collaborate with internal and external partners to publish high impact content focused on improving compliance, quality, and affordability
• Evaluate clinical and other data (e.g., quality metrics, claims data, bed-day data, usage data) to identify opportunities for improvement of clinical processes
• Develop key messages and talking points for communicating clinical program outcomes to key external stakeholders
• Continuously seek to identify potential growth opportunities and provide clinical support to UM teams, credentialing, and delegates
• Create and maintain solid relationships with key clinical leaders across Optum, UHG, and external delegates
• Participates and leads key executive meetings including LOB affordability leadership meetings, Value Creation Ideation Front door, and LOB Joint Operating Committee
• Manage challenging conversations with appropriate interpersonal dynamics when discussing programs that impact compliance, quality and/or affordability and areas of disagreement
• Deliver group presentations on clinical findings, remediation, & expected outcomes
• Influence development of technical/clinical communications that will be delivered to external audiences (e.g., new clinical policies, programs, processes)
• Discuss oversight findings with internal or external parties (e.g., case managers, other medical directors, clinical providers, physicians)
• Provide feedback to team members and other departments to refine decision making and promote a shared understanding of clinical determinations and outcomes
• Assess and interpret complex financial and clinical data to evaluate feasibility of proposed initiatives
• Identify and implement development resources in response to business needs and regulatory changes

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 (MD or DO) degree with unrestricted medical license
• 10+ years of clinical practice experience required
• 5+ years of progressive leadership experience managing teams, specifically Utilization Management teams
• 5+ years of managed care experience across the continuum of care including acute and chronic condition management, utilization management, and preventative services required
• Demonstratable application of understanding the Utilization Management continuum within the payor space, including pre-service, concurrent-review, and post-service medical management functions
• Previous experience working within a health plan
• Demonstrated accomplishments in the areas of health care delivery systems, utilization management, case management, disease management, quality management, and peer review
• Business background/experience in addition to a clinical background is a key attribute for success in this role
• Experience in provider and/or client-facing customer relationship management
• Demonstrated proficiency using InterQual, or other evidence-based guidelines, as it relates to clinical decision making
• Familiar with URAC and NCQA UM requirements
• Excellent presentation skills for both clinical and non-clinical audiences
• Solid operational focus with demonstrated data analysis / interpretation acumen, project management, change management, and execution skills
• Past success working collaboratively in a highly-matrixed environment
• Solid strategic thinking and business acumen with the ability to align clinical related strategies and recommendations with business objectives
• Adaptable and flexible style of collaborating with key stakeholders in setting direction
• Proven ability to quickly gain credibility, influence and partner with staff, business leaders and the clinical community
• Solid belief in evidence-based medicine

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy