National Medical Director, Clinical AI Innovation and Performance - Remote

Job d:

Location:

Minnetonka, Minnesota, United States Salary: $386,500 - $579,500/year

Job Area:
Medical & Clinical Operations Company:
United Health Group At United Healthcare, 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 optimized. Ready to make a difference? Join us to start Caring.

Connecting. Growing together

United

Healthcare is leveraging AI, real-time data and a modern platform to modernize clinical programs - starting with Utilization Management.  The Medical Director, Clinical AI Innovation and Performance is a senior physician leader responsible for the clinical AI model training, testing and surveillance.  Work will initially focus on utilization management (UM) clinical criteria-leveraging Inter Qual, UHC custom specialty content and other evidence-based criteria.

The MD will establish efficient and consistent annotation, training and testing models to ensure medical policies are accurately interpreted, evidence based, consistently applied, and operationally effective,  This role serves as the clinical authority for guideline interpretation, clarification, and enhancement, ensuring that approved medical policy and supporting evidence are translated into UM clinical criteria that enable appropriate coverage decisions, support safe and effective care, and scale across enterprise operations.  

The initial focus will be on Prior Authorization and will expand to include Inpatient Level of Care.  Clinical Care Management and Comprehensive Medication Management.

The clinical annotation, training and testing team will report to this physician.  The MD will be the primary clinical relationship to Foundation model clinical teams (Antrhopic, OpenAI, Gemini).
The CMO will work closely with the CMO Medical Policy, the CMO Value Creation, the CMO of Medical Management and the MD, Data Science.  MD will also be a key member of the UCS clinical and AI leadership team, collaborating on clinical program design, data models, AI use and modernization.

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

Primary Responsibilities:

Inter Qual Expertise, Interpretation & Guideline Enhancement Maintain deep expertise in Inter Qual criteria, evidence framework, and decision logic

Ensure consistent, accurate interpretation of Inter Qual criteria across:

Services, settings, and levels of care Reviewer types and UM workflows

Lead guideline clarification, customization, and enhancement where needed to:

Improve clinical clarity and consistency

Address operational ambiguity or recurring edge cases

Enhance the ability to ensure care is safe and effective

Develop and approve evidence based enhancements or supplemental criteria that add clinical clarity while remaining aligned with approved medical policy

Work closely with leaders in Medical Policy and evidence teams to ensure:

Alignment with policy intent

Clear translation of policy into UM ready clinical criteria

Evidence Based UM Clinical Criteria Ensure UM clinical criteria are:

Explicitly grounded in clinical evidence and accepted guidelines

Structured for consistent application at scale

Clear and actionable for nurses, physician reviewers, and AI enabled workflows

Apply senior clinical judgment in situations where:

Evidence is evolving or limited

Criteria require interpretation to ensure appropriate coverage decisions

Promote consistent clinical standards across UM operations while recognizing the need for appropriate clinical flexibilityUM Operations & Coverage Interpretation Leadership Ensure UM criteria function effectively in production environments:

Supporting timely and appropriate coverage decisions

Reducing unwarranted variation across reviewers

Aligning clinical interpretation with operational reality

Partner closely with UM Operations and Nursing leadership to:

Identify areas of confusion or friction in criteria application

Address recurring themes from operational feedback

Improve reviewer confidence and consistency

Clinical Annotation & LLM Training for UMLead teams responsible for clinical annotation and analysis supporting LLM based UM decision support

Oversee the clinical review process that ensures:

Accurate interpretation of UM criteria by LLMsReliable assessment of whether clinical documentation meets…