The Medical Director leads the claims review program reviews surgical claims participates in coding compliance and supports staff training.

Requisition Number: 2343297
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 inclusion talented peers comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
As part of the Focus Claims Review team at Optum the Medical Director provides leadership organization and direction for the claims review program. 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 coding and procedures.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:

• Remote Schedule: Monday through Friday flexible 8 hr. shifts; no weekends
• Reviews surgical & spinal 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
• Discuss cases and clinical coding situations with treating providers telephonically during scheduled hours
• Participates in periodic coding conferences / calls and in ongoing internal performance consistency reviews
• 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 Orthopedic Surgery
• 5+ years of clinical experience in Orthopedic surgery; specialized in spinal surgery post residency
• Proficient in MS Office (MS Word Excel and Power Point)

Preferred Qualifications:

• Experience in managed care
• 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 $248500.00 to $373000.00 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.
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race national origin religion age color sex sexual orientation gender identity disability or protected veteran status or any other characteristic protected by local state or federal laws rules or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.