CCAT Medical Director - Remote

UnitedHealth Group•Plymouth, MN

4d•Remote

About The Position

This Medical Director role in the Clinical & Coding Advisory Team (CCAT) is a rare opportunity to work directly within Optum Payer Operations. As a member of CCAT, you will play a vital role in helping stop fraud, waste, abuse, and error, ensure correct payment of claims and help healthcare work better every day. The purpose of the Optum Payment Integrity Medical Director is to provide expert clinical insight of provider claims. Key responsibilities include but are not limited to conducting clinical claim reviews, educating providers, managing high-level appeals, developing industry-leading clinical resources, and driving operational improvements. This position serves as a forward-facing clinical expert within Optum, representing clinical strategy and payment integrity operations, and offering clinical and coding oversight across UnitedHealthcare and commercial clients. The role requires collaboration with valued clients and operational teams to ensure accurate claim payment, prevent fraud, waste, and abuse, and support ongoing enhancements in clinical and coding practice, aligned with UnitedHealth Group’s dedication to helping people live their lives to the fullest. 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 non-restricted licensed MD or DO physician
5+ years of clinical practice experience
2+ years of experience in clinical operations within a health plan/or managed care environment to include client facing experience
Thorough knowledge of CPT/HCPCS/ICD-10 coding, the health insurance business, and knowledge of industry terminology and regulatory guidelines
Familiarity with current medical issues and practices

Nice To Haves

3+ years in facility (DRG and Clinical Validation Audit) Reviews
Coding Certification with AHIMA (CCS, CDIS, RHIA, RHIT) or AAPC (CIC, CPC)
Experience with appeals and peer-to-peer conversations
Experience in managing claims related to Fraud, Waste, Abuse and Error
Experience with Encoder and Grouper Software (3M)
Knowledge of federal (e.g., CMS) and state laws and regulations

Responsibilities

Provide expert clinical and strategic leadership for operational teams
Collaborate and support clinical operations teams on complex cases
Apply clinical and medical coding knowledge in the interpretation of medical policy, clinical resources, and benefit document language in the review of professional claims, itemized bills, and facility, pre-pay and post-pay clinical reviews
Collaborate and educate network and non-network providers on cases and clinical coding situations in pursuit of accurate billing practices
Actively participate in regular meetings and projects focused on clinical claim decision-making, clinical resources, analytics, savings, and staff training
Participate in development of medical policy, clinical resources, and guidelines utilized in the review of professional and facility pre-pay and post-pay clinical reviews
Other duties and goals assigned by the Senior Medical Director