Claims Review Medical Director Spine Surgery

Unitedhealth Group Inc. White Plains , NY 10601

Posted 2 months ago

As part of the 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 OrthoNet. 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 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 OrthoNet, physicians, and other medical service providers in selected situations primarily related to medical claim reviews.

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 occasional, 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 travel to scheduled company meetings and activities in US

  • 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

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 an ABMS specialty

  • 5 years clinical experience in Orthopedic surgery post residency with Sub-Specialty training in Spine surgery

  • Use and knowledge of coding and billing practices

  • Proficient computer skills to include MS Office (MS Word, Excel, and Power Point)

  • Ability to learn to use OrthoNet clinical and claims software

  • Must be able to work Eastern Standard Time hours

Preferred Qualifications:

  • Experience in managed care

  • Prior 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

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Claims, Review, Medical Director, Spine, Surgery, White Plains, New York, NY


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