UM Medical Director - Orthopedic Spine, Neurosurgery or Spine Surgery - Remote

UnitedHealth Group•Minneapolis, MN

1d•Remote

About The Position

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. Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company. The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Current, active and unrestricted medical license
Current Board Certification in Orthopedic Surgery or Neurosurgery
5+ years clinical experience post residency in Orthopedic Surgery or Neurosurgery to include experience with musculoskeletal/ spine surgery
Sound understanding of Evidence Based Medicine (EBM)
Proficient with MS Office (MS Word, Email, Excel, and Power Point)
Excellent computer skills and ability to learn new systems and software
Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
Willing to obtain additional licenses as needed

Nice To Haves

Active license in South Carolina, Minnesota or Texas, but candidates with an active license in other states are acceptable
ABMS or other nationally recognized further specialized certifications
Experience in managed care UM activities/ coverage reviews
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
Possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments

Responsibilities

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for spine surgery
Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers)
Works with clinical staff to coordinate all the necessary coverage reviews and provides feedback to staff who do portions of the coverage reviews
Engage with requesting providers as needed in peer-to-peer discussions
Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews
Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
Communicate and collaborate with other internal partners
Call coverage rotation. Is available for periodic weekend and holiday coverage as needed for telephonic and remote computer expedited clinical decisions
Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable
Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations