UnitedHealthcare

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

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The Senior Medical Director for UnitedHealthcare’s Payment Integrity (UHC PI) Organization is a valuable national leader for UnitedHealthcare. The position is forward-facing with provider facility executives, professional groups, laboratories, and UHC PI vendors. The Senior Medical Director oversees a clinical and coding team, ensuring accurate and efficient healthcare payments, accurate appeal outcomes, and collaborates with clinical and coding teams across UnitedHealthcare and Optum, as well as UHG business leaders, to drive informed decision-making and optimize outcomes.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• Oversee and perform individual case review for facility appeals for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations of facility clinical validation audits for medical services and the application of clinical criteria of medical policies
• Provide clinical oversight and guidance to UHC 3rd party vendors engaged in clinical payment integrity reviews
• Perform Department of Insurance/Department of Managed Healthcare, and CMS regulatory and IRE responses
• Oversee the Independent Review Organization Process
• Document clinical validation audit findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements
• Communicate with UnitedHealthcare medical directors regarding coding/clinical validation appeals rationales
• Communicate with UnitedHealthcare Regional and Plan medical directors and network management staff regarding clinical payment integrity reviews/audits
• Support the Payment Integrity team in their interactions with providers to explain review/ audit findings and the application of coding/clinical criteria
• Engage with requesting providers as needed in peer-to-peer discussions
• Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results
• Provide clinical and strategic input when participating in organizational committees, projects, and task forces
• Develop quality audit practices to ensure UHC 3rd party vendors are adhering to proper coding/clinical guidelines and ensuring clinical justification meets expected standards
  
  

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 license
• Board Certified in an ABMS or AOBMS specialty
• 5+ years of clinical practice experience
• 2+ years of Quality Management experience
• Familiarity with current medical issues and practices
• Proficiency in performing medical record case reviews for hospital claims in accordance with established reimbursement and medical policies
• Intermediate or higher level of proficiency with managed care
• Proven excellent telephonic communication skills; excellent interpersonal communication skills
• Proven excellent project management skills
• Proven data analysis and interpretation skills
• Proven excellent presentation skills for both clinical and non-clinical audiences
• Proven creative problem-solving skills
• Proven basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
• Proven solid team player and team building skills
  
  

Preferred Qualification

• Coding experience or certification (CPC, CCS, etc.)
  
  

If the hired individual resides in Florida (office based or telecommuting) this position requires the AHCA Level II background check (fingerprinting) by the State of Florida for all clinicians that have direct face to face contact with members OR employees who will have access to confidential patient data and will require renewal every five years.

• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
  
  

Compensation for this specialty generally ranges from $278,000 - $417,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. 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). No matter where or when you begin a career with us, 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.

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.