Remote Utilization Review Rn Jobs in Plymouth, MN

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UnitedHealthcare 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 InterQual, 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:

• InterQual Expertise, Interpretation & Guideline Enhancement
  • Maintain deep expertise in InterQual criteria, evidence framework, and decision logic
  • Ensure consistent, accurate interpretation of InterQual 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 flexibility
• UM 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 UM
  • Lead 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 LLMs
    • Reliable assessment of whether clinical documentation meets criteria
  • Provide clinical oversight and judgment where:
    • Annotator disagreement exists
    • Criteria vary in complexity or trainability
    • Additional training data or clarification is required
  • Ensure annotation and training processes support clinically accurate, reliable model performance
• AI Lifecycle Participation & Governance (UCS Led)
  • Serve as a senior physician leader within UCS led AI governance, under the authority of the UHC CMO
  • Participate in reviews across AI lifecycle phases:
    • Training and validation
    • Shadow mode
    • AI assist (clinical in the loop)
    • Production deployment
  • Contribute clinical judgment to evaluations of:
    • Precision and recall
    • Clinical accuracy and safety
    • Readiness for use in automated approvals
  • Identify areas where additional training, refinement, or safeguards are required
• Cross Functional Clinical Leadership & Continuous Improvement
  • Directly manage:
    • Clinical annotators
    • Clinical or UM analysts supporting AI enablement and criteria oversight
  • Work closely with:
    • Medical Policy leadership
    • CARES team conducting rigorous UM case review and quality evaluation
    • UM Operations and Appeals
    • Product, ECS, and AI / data science teams
  • Ensure insights from production, appeals, audits, and quality reviews inform:
    • Guideline clarification and enhancement
    • Reviewer guidance
    • Ongoing improvement of AI model performance and safety

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:

• MD or DO with active/unrestricted U.S. Medical Licensure
• Board certification in an ABMS/AOBMS Clinical specialty
• Significant experience in:
• Utilization management
• Coverage interpretation using UM clinical criteria
• Clinical operations in large, complex organizations
• Demonstrated experience working with InterQual clinical criteria
• Experience with UM physicians and nursing teams at scale
• Proven ability to lead through influence across clinical, operational, and technical teams

Preferred Qualifications:

• Experience across Commercial and/or Government program UM
• Experience working with MCG guidelines
• Proven direct responsibility for UM operations leadership
• Proven exposure to AI enabled clinical workflows or advanced decision support (technical expertise not required)

Leadership Profile (Senior Leadership Team Level)

• Recognized clinical authority with strong peer credibility
• Demonstrated judgment in complex or ambiguous clinical scenarios
• Able to operate at enterprise scale while maintaining clinical rigor
• Comfortable providing clinical guidance on AI use in high impact workflows
• Trusted advisor to executive leadership across UCS and UHC

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $386,500 - $579,500 annually based on full-time employment. We comply with all minimum wage laws as applicable."
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.
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.
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.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.