Medical Director - Pharmacy - Remote
Company: Optum
Location: Tempe
Posted on: May 26, 2025
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Job Description:
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.
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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.
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You'll enjoy the flexibility to work remotely * from anywhere
within the U.S. as you take on some tough challenges.
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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
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- Other duties and goals assigned by the medical director's
supervisor
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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 Internal Medicine, Family
Practice or Emergency Medicine
- 5+ years of clinical practice experience after completing
residency training
- Substantial experience in using electronic clinical
systems
- 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
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Preferred Qualifications:
- Board certification in Gastroenterology, Rheumatology,
Hematology-Oncology
- Hands-on experience in utilization review
- Clinical practice experience in the last 2 years
- Data analysis experience
- Sound knowledge of the managed care industry
- Data analysis and interpretation experience and skills
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- Reside in PST or MST
- Excellent presentation skills for both clinical and
non-clinical audiences
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*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
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The salary range for this role is $238,000 to $357,500 per year. 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 local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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, you'll find a far-reaching choice of benefits and incentives.
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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.
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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.
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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.
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UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
Keywords: Optum, Tucson , Medical Director - Pharmacy - Remote, Executive , Tempe, Arizona
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