Associate Director - Remote

Assistant Director, Medical Management

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.

The Assistant Director provides clinical expertise, claim risk assessment, cost containment support, and leadership for the Medical Management team. This role supports underwriters, claims auditors, vendor partners, brokers, administrators, and internal teams by evaluating high-risk claimants, estimating cost of care, identifying cost containment opportunities, and serving as a clinical resource across the organization.

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

• Large Claim Notice Review and Risk Assessment
  - Approximately 25%
  • Review and assess large claim notices for potential risk within 48 business hours of receipt
  • Set up potential high-dollar claimants in POWER for ongoing risk assessment and reserve allocation
  • Monitor claimants monthly or biweekly, based on severity and changes in treatment
  • Apply clinical and cost knowledge to determine when claimants should be established for ongoing monitoring
  • Notify the underwriter and claims auditor when potential risk is first identified and provide updates as risk changes
• Clinical Education and Research
  • Educate non-medical internal and external customers on clinical trends, treatments, and possible outcomes
  • Research medical conditions and disease states to support appropriate treatment understanding for specific conditions
  • Use reputable clinical resources, such as NCCN, CDC, Predict Dx/Rx, and Profiler, as needed
• Cost Containment Assessment
  - Approximately 20%
  • Assess all claimants for potential cost containment opportunities
  • Collaborate with TPAs, case managers, claims auditors, underwriters, and vendors to identify and implement appropriate cost containment measures
• Diary Follow-Up and Documentation
  - Approximately 10%
  • Maintain timely diary follow-up for all claimants open in POWER
  • Index all documentation received
  • Co-manage complex medical cases with the Transplant/Dialysis Coordinator
• Clinical Claim File Review
  - Approximately 5%
  • Provide clinical claim file review support for claims auditors as needed
  • Perform appropriate research for each clinical claim file review request
  • Discuss findings and answer claims auditor questions as needed
  • Perform experimental and investigational file reviews for Claims
  • Review PYCS to assist the claims auditor in setting appropriate reserves based on known or anticipated costs
• Cost Estimator Requests
  - Approximately 40%; up to 75% during busy season
  • Review all documents indexed into the package for each cost estimator request
  • Perform appropriate research for each cost estimator request
  • Identify actual and potential risks for each request
  • Document a clinical summary and estimate the cost of care for each individual identified as at risk
  • Re-review additional information and update cost estimates as needed
  • Complete cost estimate requests for new business within 24 business hours of receipt and renewal business within 48 business hours of receipt
  • Discuss findings and answer underwriter questions as needed
• Hot Claims Reporting
  • Complete Hot Claims reports as needed to track large claims and cost containment strategies implemented
• Leadership and Team Support Responsibilities
• Subject Matter Expertise and Team Development
  • Serve as a subject matter expert for the underwriting team and act as the first point of contact for questions, concerns, and education related to clinical responsibilities
  • Serve as a clinical resource and provide coaching and training to new or less experienced team members
  • Assist with training and orientation for new employees
  • Continue researching new treatments and clinical trends and share relevant knowledge with the broader team
• Clinical Policy, Quality, and Communication
  • Participate in the development of clinical policies for the Medical Management team
  • Facilitate monthly clinical communication calls on a rotational basis
  • Perform the monthly LCN quality assurance process for the team and report results to the Director
• Process Improvement and Business Growth
  • Participate in cross-functional teams to develop or enhance workflow processes
  • Identify new processes and changes to existing processes that support company growth and success
  • Assist in developing consistency for implementation calls with new customers
  • Continue learning the business aspects of the clinical function to support readiness for future Director-level opportunities
• Vendor, Broker, and Customer Engagement
  • Work with internal and external vendor partners to learn more about cost containment opportunities and explain the team's role, objectives, and value
  • Increase regular interaction with…