Medical Director - UnitedHealthcare Community & State (Wisconsin)

Role Overview The Chief Medical Officer for UnitedHealthcare Community & State Wisconsin 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 Director of Clinical Operations 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 Wisconsin DHS, ForwardHealth requirements, and applicable state and federal regulations. Reporting Structure Reports to: Chief Executive Officer, Community & State Wisconsin Works closely with: Clinical, Quality, Population Health, Provider Engagement, and Operations leaders Location: If you are located in Wisconsin, 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 Wisconsin 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 Review all member and provider appeals and grievances and provide clinical information and leadership to the weekly Appeals Panel Hearing calls 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 strong relationships with provider organizations, health systems, and community partners to support quality, utilization, and member experience goals Work closely with the Wisconsin Department of Health Services (DHS), including close collaboration with the DHS Chief Medical Officer and the Chief Medical Officers of other Wisconsin Medicaid HMO Plans on statewide quality and performance initiatives Apply knowledge of Wisconsin DHS and ForwardHealth 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 Executive 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 Solid clinical leadership and sound medical judgment Knowledge of Medicaid and Wisconsin ForwardHealth 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 Required Qualifications MD or DO with an active, unrestricted Wisconsin 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 Work Location Wisconsin‑based role with remote flexibility Occasional in‑state travel may be required Remote employees must follow UnitedHealth Group's Telecommuter Policy *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation and Benefits 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. 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. Equal Employment Opportunity 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. Drug Test Requirement UnitedHealth Group is a drug‑free workplace. Candidates are required to pass a drug test before beginning employment. #J-18808-Ljbffr