As part of the Focus Claims Review team at Optum, the Medical Director provides leadership, organization, and direction for the claims review program. They are responsible for the overall quality, effectiveness and coordination of the medical services provided through Optum. The Medical Director will participate in all aspects of claim review services including provider telephonic discussions and provider appeals. In addition, the Medical Director may also be asked to assist in the direction and oversight in the development and implementation of policies and procedures and clinical criteria for all medical programs and services. The Medical Director will serve as a liaison between Optum, physicians, and other medical service providers in selected situations primarily related to medical claim reviews.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:- Reviews surgical and other professional claims for correct coding using clinical record
- Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable
- Discusses cases and clinical coding situations with treating providers telephonically during scheduled hours
- Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews
- Composes, if needed, patient situation specific, clinical summaries and rationales for medical necessity decisions
- Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers)
- Provide Clinical support for staff that conduct initial reviews
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, active, and fully unrestricted medical license
- Current board certification in General Surgery through the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)
- 5+ years of clinical experience with brain and spine surgeries post residency
- MS Office (MS Word, Excel, and Power Point)
Preferred Qualifications:- Experience working for a managed care organization
- Experience with professional claim coding / claim coding reviews
- Knowledge of claim coding resources and techniques
- Proficient computer skills and ability to learn to use clinical and claims software
- Proven excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
*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 $248,500 - $373,000 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.
