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Orthopedic or Spine Medical Director, Utilization Management - Telecommute

UnitedHealth Group

White Plains, NY
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Job Details

739770 Orthopedic Medical Director Utilization Management Telecommute

Orthopedic or Spine Medical Director, Utilization Management - Telecommute (739770)

Position Description

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.


Responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services provided through OrthoNet. 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 will participate in the monitoring of patient care progress, treating physician medical decision making in the context of utilization management and coordinates provider appeals
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. S/he may serve as a liaison between OrthoNet, physicians, and other medical service providers in selected situations   


Primary Responsibilities:

  • Performs utilization management reviews for various types of musculoskeletal and other medical / surgical services which may include PT OT ST, home health care, SNF, LTAC and acute inpatient rehabilitation services.
  • Works with OrthoNet clinical staff to coordinate all the necessary UM processes and provides feedback to OrthoNet staff who do portions of the UM reviews
  • Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable
  • Discusses cases and clinical 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
  • Good understanding of professional performance measurement and related possible discussions/interventions with selected providers / groups / organizations

Required Qualifications:

  • Current, active and unrestricted Medical license
  • Active Board certification in ABMS - recognized specialty applicable to this specialty area
  • 5+ years clinical experience in relevant important aspects of musculoskeletal medicine and surgery
  • Experience in managed care UM activities
  • Excellent verbal and written communication skills
  • Diplomacy and tact in dealing with sensitive issues
  • Must possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments
  • 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
  • Proficient computer skills and ability to learn to use OrthoNet clinical and claims software
  • Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
  • Proficiency in MS Office (MS Word, Excel, and Power Point)

Preferred Qualifications:

  • ABMS or other nationally-recognized further specialized certifications
  • Prior experience with pre-certification and professional claim coding / claim coding reviews

UnitedHealth Group is working to create the health care system of tomorrow.

Already Fortune 6, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we're doing a lot of good.

Through our family of businesses and a lot of inspired individuals, we're building a high-performance health care system that works better for more people in more ways than ever. Now we're looking to reinforce our team with people who are decisive, brilliant - and built for speed.

Come to UnitedHealth Group, and share your ideas and your passion for doing more. We have roles that will fit your skills and knowledge. We have diverse opportunities that will fit your dreams.

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.


Job Keywords: Physician, MD, Medical Director, Clinical, quality management, utilization review, utilization management, ortho, orthopedic, Telecommute, remote

Job Details

  • Contest Number739770
  • Job TitleOrthopedic or Spine Medical Director, Utilization Management - Telecommute
  • Job FamilyMedical and Clinical Operations
  • Business SegmentOptum Corporate

Job Location Information

  • White Plains, NY
    United States
    North America
  • Other LocationsAtlanta, GA
    Chicago, IL
    New York, NY
    Dallas, TX
    Buffalo, NY

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job Level
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionYes
  • Overtime StatusExempt

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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