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.

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.

Primary 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

Is available for occasional, periodic weekend and holiday as needed telephonic and remote computer expedited clinical decisions

Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers)

Ability to travel to scheduled company meetings and activities in US

Ability to assist in marketing presentations to clients and ongoing relationship management activities with existing clients if requested to do so

Provide Clinical support for staff that conduct initial reviews

Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations

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 Neurosurgery or Orthopedic surgery

5+ years of clinical experience in Neurosurgery or Orthopedic surgery; specialized in spinal surgery post residency

MS Office (MS Word, Excel, and Power Point)

Preferred Qualifications:

Experience in managed care

Experience with professional claim coding / claim coding 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

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

California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.