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Medical Director, Plastics / Dermatology - Telecommute

UnitedHealth Group

White Plains, NY
Job Code:
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Job Details

Medical Director, Plastics / Dermatology - Telecommute(Job Number:728474)

Clinical Services is focused on driving measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability. In serving our Medicare, Medicaid, and commercial members & plan sponsors, our Clinical Services teams partner with our network of physicians, hospitals and other health care professionals to achieve these goals. We are committed to our mission of helping people live healthier lives and inspire your life's best work. (sm)

The Medical Director provides leadership, organization, and direction for claims review programs and may assist in the Utilization management programs and services.  Responsible for the overall quality, effectiveness and coordination of the medical services provided through OrthoNet.  Direct aspects of the medical claims reviews and coordinates these with the Quality Improvement programs for the company.  The Medical Director will participate in the all aspects of claim review services including provider telephonic discussions and provider appeals.  
The Medical Director may also be asked to assist assists in the direction and oversight in the development and implementation of Policies and procedures and clinical criteria for all medical programs and services.  S/he will serve as a liaison between OrthoNet, physicians, and other medical service providers in selected situations primarily related to medical claim reviews.  
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
  • May assist in aspects of the utilization management and quality improvement programs.
  • 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
  • Good understanding of professional performance measurement and related possible discussions/interventions with selected providers / groups / organizations

Job Clinical Analysis & Consulting
Primary Location US-NY-White Plains
Other Location US-TX-Dallas, US-NY-New York, US-GA-Atlanta, US-NY-Buffalo, US-IL-Chicago
Organization Talent Acquisition
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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