UnitedHealth Group
Utilization and Clinical Review - Medical Director - Orthopedic Surgery - Remote
UnitedHealth Group, Minneapolis, Minnesota, United States, 55400
Overview
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
Position Summary 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.
Primary 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 surgical procedures and other medical/surgical services for musculoskeletal procedures including therapy
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
Rewards and Recognition 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
MD or DO with an active, unrestricted medical license
Current, active and unrestricted medical license
Willing to obtain additional licenses as needed
Board Certification in Orthopedic Surgery
5+ years clinical practice experience post residency
Sound understanding of Evidence Based Medicine (EBM)
Proficient with MS Office (MS Word, Email, Excel, and Power Point)
Proven excellent computer skills and ability to learn new systems and 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
Preferred Qualifications
2+ years managed care, Quality Management experience and/or administrative leadership experience
Experience in utilization and clinical coverage review
Clinical experience within the past 2 years
Remote Work Policy *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Compensation 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). The salary for this role will range from $269,500 to $425,500 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Equal Opportunity & EEO 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.
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Position Summary 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.
Primary 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 surgical procedures and other medical/surgical services for musculoskeletal procedures including therapy
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
Rewards and Recognition 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
MD or DO with an active, unrestricted medical license
Current, active and unrestricted medical license
Willing to obtain additional licenses as needed
Board Certification in Orthopedic Surgery
5+ years clinical practice experience post residency
Sound understanding of Evidence Based Medicine (EBM)
Proficient with MS Office (MS Word, Email, Excel, and Power Point)
Proven excellent computer skills and ability to learn new systems and 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
Preferred Qualifications
2+ years managed care, Quality Management experience and/or administrative leadership experience
Experience in utilization and clinical coverage review
Clinical experience within the past 2 years
Remote Work Policy *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Compensation 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). The salary for this role will range from $269,500 to $425,500 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Equal Opportunity & EEO 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.
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