Clinical Services is focused on driving measurable and meaningful improvement in the use of evidence - based medicine, patient safety, practice variation and affordability. In serving our Medicare, Medicaid, and commercial members & plan sponsors, our Clinical Services teams partner with our network of physicians, hospitals and other health care professionals to achieve these goals. We are committed to our mission of helping people live healthier lives and inspire your life's best work. (sm)
The Medical Director provides leadership, organization, and direction for claims review programs and may assist in the Utilization management programs and services. Responsible for the overall quality, effectiveness and coordination of the medical services provided through OrthoNet. Direct aspects of the medical claims reviews and coordinates these with the Quality Improvement programs for the company. The Medical Director will participate in the all aspects of claim review services including provider telephonic discussions and provider appeals.
The Medical Director may also be asked to assist assists 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.
- 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
- May assist in aspects of the utilization management and quality improvement programs.
- 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
- Good understanding of professional performance measurement and related possible discussions / interventions with selected providers / groups / organizations
- Current, active and unrestricted Medical (MD or DO) license
- Active Board certification in ABOS or AAOS specialty
- May consider active board certification in ABMS - recognized specialty applicable to this specialty area ABMS or other nationally - recognized further specialized certifications are a plus
- 5+ years clinical practice experience post residency
- Prior experience with professional claim coding / claim coding reviews is essential
- Knowledge of all important claim coding resources and techniques
- Excellent verbal and written communication skills
- Diplomacy and tact in dealing with sensitive issues
- Must possess 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
- Proficient computer skills and ability to learn to use OrthoNet clinical and claims software
- Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
- MS Office (MS Word, Excel and Power Point)
- Experience in managed care preferred
UnitedHealth Group is working to create the health care system of tomorrow.
Already Fortune 6, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we're doing a lot of good.
Through our family of businesses and a lot of inspired individuals, we're building a high-performance health care system that works better for more people in more ways than ever. Now we're looking to reinforce our team with people who are decisive, brilliant - and built for speed.
Come to UnitedHealth Group, and share your ideas and your passion for doing more. We have roles that will fit your skills and knowledge. We have diverse opportunities that will fit your dreams.
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: Physician, MD, Medical Director, Clinical, quality management, ortho, orthopedics, spine