Focus Claims Review - Medical Director, Orthopedic Surgery - Remote

Company: UnitedHealth Group
Location: San Jose
Posted on: September 15, 2023

Job Description:

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.
Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale.
Join us to start
Caring. Connecting. Growing together.--

As part of the Optum Enterprise Clinical Services, Focus Claims Review team, 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 FCR. 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.-- S/he will serve as a liaison between FCR, 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
  
• Is available for rare, periodic weekend and holiday as needed telephonic and remote computer expedited clinical decisions
  
• Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third party payers)
  
• Ability to assist in marketing presentations to clients and ongoing relationship management activities with existing clients if requested to do so
  
• Provide Clinical support for staff that conduct initial reviews
  
• Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations
  
• May be asked to support other areas based on business need
  
  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
    
  • Board certified in Vascular Surgery
    
  • 5+ years of clinical experience in Vascular Surgery post residency
    
  • Demonstrated use and knowledge of coding and billing practices
    
  • Proficient computer skills to include MS Office (MS Word, Excel, and Power Point)
    
    Preferred Qualifications:------------------
    
    • Sub-Specialty training in Spine, Hand, Joint, Foot and Ankle or Sport
      
    • Experience with professional claim coding resources/claim coding reviews and techniques
      
    • Exhibits leadership skills in working with other physicians, knowledge of the overall medical community and the local/regional managed care environments
      
    • Experience with integration of clinical and financial data, development of utilization and performance reporting tools, and communication of performance data to physicians and other health care providers
      
      *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy--
      
      California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $ 248,582 to $338,965. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, 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.--------
      
      
      Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.--
      
      OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: UnitedHealth Group, San Jose , Focus Claims Review - Medical Director, Orthopedic Surgery - Remote, Executive , San Jose, California