Impress employers and recruiters.
Choose from hundreds of resume examples.

Target Resume Now

About the Role

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.

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

Requirements

Current, active, and fully unrestricted medical license
Current board certification in Plastic Surgery
5+ years of clinical experience in Plastic Surgery post residency
Knowledge or proficiency in MS Office (MS Word, Excel, and Power Point)
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
Candidates are required to pass a drug test before beginning employment.

Skills

Managed care
Professional claim coding / claim coding reviews
Integration of clinical and financial data
Development of utilization and performance reporting tools
Communication of performance data to physicians and other health care providers
Claim coding resources and techniques
Proficient computer skills and ability to learn to use clinical and claims software
Excellent interpersonal skills
Ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel

Location

Remote (United States)

Work Type

Full-time
Work from home
40 hours per week
Monday through Friday

Experience Level

5+ years of clinical experience in Plastic Surgery post residency

Education Level

Board certification in Plastic Surgery

Salary/Compensations

$248,500 to $373,000 annually

Benefits

Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution

About the Company

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.
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.

Equal Opportunity

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.