Medical Director - Spine and Brain Surgery - Remote

UnitedHealth Group•Minneapolis, MN

4h•Remote

About The Position

As part of the Focus Claims Review team at Optum, 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 Optum. 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. The Medical Director will serve as a liaison between Optum, 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.

Requirements

Current, active, and fully unrestricted medical license
Current board certification in Neurological Surgery
5+ years of clinical experience with brain and spine surgeries post residency
MS Office (MS Word, Excel, and Power Point)

Nice To Haves

Experience working for a managed care organization
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

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
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