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.
Primary Responsibilities:- 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 administrators and brokers to provide education where needed
- Build trust and collaboration with brokers and vendors
- Director Support and Management Participation
- Provide coverage for the Director when she is out of the office, ensuring metrics are met by required due dates and workflow remains on track
- Begin attending monthly management calls when appropriate
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:- Current and unrestricted RN license in the state of residence
- 5+ years of clinical experience
- 4+ years of experience working in the Stop Loss industry, TPA's or managed care company
- 2+ years of ER, critical care or oncology experience
- Managerial experience
- Proficient in Microsoft Excel
Preferred Qualifications:- Training experience
- Demonstrated ability to multitask and remain organized
*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 $112,700 - $193,200 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.
