Remote Utilization Review Jobs in Boca Raton, FL

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The Associate Medical Director for UnitedHealthcare Community & State Florida is an important clinical leadership role focused on improving quality, supporting thoughtful medical decision-making, and enhancing the member and provider experience across Medicaid, D-SNP, and LTC populations.

Working closely with the Chief Medical Officer and cross-functional partners, this role offers the opportunity to shape utilization management, quality improvement, provider collaboration, and population health efforts while helping ensure alignment with the Florida Agency for Health Care Administration (AHCA) requirements and applicable state and federal regulations.

Reporting Structure

• Reports to: Chief Medical Officer, Community & State Florida
• Works closely with: Quality, Population Health, Provider Engagement, and Operations leaders

Work Location

• Florida-based role with remote flexibility
• Occasional in-state travel may be required
• Remote employees must follow UnitedHealth Group's Telecommuter Policy

If you are located in FL, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Provide clinical leadership for utilization management, prior authorization, appeals and grievances, and provider quality activities across Florida Medicaid, LTC, and D-SNP populations
• Support timely, evidence-based coverage decisions aligned with clinical guidelines, plan policies, and regulatory expectations
• Partner with United Clinical Services and enterprise teams to support regulatory changes and strengthen clinical operations
• Participate in clinical rounds, conduct peer-to-peer reviews, and represent the health plan in Medicaid fair hearings as appropriate
• Contribute to performance goals related to HEDIS, STAR Ratings, CAHPS, and NPS
• Identify care gaps and help advance evidence-based interventions that improve clinical quality and member outcomes
• Participate in peer review activities, including Quality of Care and Quality of Service evaluations
• Provide clinical leadership during interdisciplinary rounds and support evidence-based standards of care
• Promote evidence-based practice and standardized clinical approaches that support high-quality care
• Engage network providers to address care gaps, support quality improvement, and encourage evidence-based practice
• Build solid relationships with provider organizations, health systems, and community partners to support quality, utilization, and member experience goals
• Apply knowledge of AHCA requirements and applicable state and federal Medicaid regulations to support compliant clinical operations
• Support implementation of policy and process changes that enhance clinical programs and operations
• Help reduce unwarranted variation in care through provider education, engagement, and best practices

Leadership Expectations

• Partner with the Chief Medical Officer and plan leadership to help advance clinical strategies aligned with market, regulatory, and organizational priorities
• Support development and execution of care models that improve outcomes and member experience
• Mentor and support clinical and operational colleagues to encourage growth, collaboration, and strong performance
• Help foster a culture of accountability, collaboration, and continuous improvement
• Bring clinical insight into care management, population health, and quality improvement initiatives
• Contribute to strategic planning, program development, and operational priorities

Core Competencies

• Strong clinical leadership and sound medical judgment
• Knowledge of Medicaid and Florida AHCA regulatory requirements
• Experience with utilization management and medical decision-making
• Commitment to quality improvement and population health outcomes
• Ability to build strong provider and partner relationships
• Collaborative leadership across cross-functional teams
• Strategic thinking with strong operational follow-through

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 an active, unrestricted Florida medical license
• Active/unrestricted Board certification in an ABMS/AOBMS Specialty
• 5 years of post-residency clinical practice experience with strong clinical judgment
• Proven solid communication skills and the ability to work effectively across clinical, operational, and provider-facing teams

Preferred Qualifications:

• Experience in managed care, utilization management, and/or appeals and grievances
• Experience supporting Medicaid, D-SNP, and/or LTC populations in a health plan, managed care, or value-based care setting
• Experience building provider relationships and collaborating across teams in a matrixed environment
• Knowledge of quality improvement, population health, and applicable regulatory requirements

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

Compensation for this specialty generally ranges from $248,500.00 to $373,000.00. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. 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.

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.