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Sr Medical Director, Payment Integriy-Claims Adjudication

UnitedHealth Group

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Job Details

744915 Senior Medical Director Claims Adjudication

Sr Medical Director, Payment Integriy-Claims Adjudication (744915)

Position Description

Medical Director careers at UnitedHealth Group are anything but ordinary. We push ourselves and each other to find smarter solutions. The result is a culture of performance that's driving the health care industry forward. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Join us. And start doing your life's best work.(sm)


The Senior Medical Director, Claims Adjudication & Payment Integrity is responsible for providing expertise and general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances. They will communicate with appropriate parties regarding appeals and grievance issues, implications and decisions and analyze and identify trends for all appeals and grievances. This role may research and resolve written Department of Insurance complaints and complex or multi - issue provider complaints submitted by consumers and physicians / providers.  The Senior Medical Director will work to develop and maintain relevant algorithms and methodologies to identify trends and improvement opportunities. They will be responsible for investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities; this may include initiating telephone calls to members, providers and other insurance companies to gather coordination of benefits data.


This position will investigate and pursue recoveries and payables on subrogation claims and file management, process recovery on claims and ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance. They will as needed, conduct contestable investigations to review medical history and may also monitor large claims including transplant cases. This Senior Medical Director will be accountable for providing expertise and general claims support to teams involved in reviewing, researching, investigating, negotiating, processing and adjusting claims. They will authorize the appropriate payment or refer claims to investigators for further review. Additionally, this individual will conduct data entry and re-work; analyzing and identifying trends and providing reports as necessary. In partnership with physician and market leaders, this role will lead discussions to identify best practices and lift and scale practices in order to improve patient outcomes, strengthen performance, and ensure strategic planning and financial objectives align with operational execution.  



If you are located in Texas, you will have the flexibility to telecommute* as you take on some tough challenges.



Primary Responsibilities:

  • Develop and grow strong partnerships with regional medical directors and local physician champions to execute on enterprise strategy and objectives

  • Serve as leadership champion for the integration of enterprise quality and risk adjustment strategy within the WellMed markets 

  • Leads the short and long term planning process and drives prioritization to meet the enterprises financial performance goals

  • Work with Regional Leadership to develop and implement best practices and consistent process / tools across WellMed

  • Leverage existing model process and attestation system to identify gaps that would improve metrics and clinical documentation

  • Ensure application of clinical algorithms within attestation process to enhance ability of providers to assess and document the complete health status of members

  • Identify operational issues / barriers and provide recommendations to executive leadership and regional market leaders to increase efficiency and maximize results

  • Partners with leadership team to coordinate provider mentoring / education regarding risk adjustment and quality improvement program components

  • Forms internal and external strategic relationships which will support program innovation, growth, expansion and the development of new programs

  • Works closely with Enterprise leadership to provide updates, feedback, metrics as well as identification for opportunities for improvement of goal driven improvement metrics

  • Directs others to resolve business problems that affect multiple functions or disciplines

  • Develops, translates and executes strategies or functional / operational objectives for a region, line of business, or major portion of a business segment functional area

  • Directs others to resolve highly complex or unusual business problems that affect major functions or disciplines

  • Develops, translates and executes strategies or functional and operational objectives at the business unit, multiple markets / sites and segment level

Required Qualifications:

  • Active, unrestricted MD / DO license

  • Board Certified in a Medical Sub - Specialty

  • Proven track record in leading major organizational strategy and leading multi - market teams in implementing strategy and objectives

  • Strong and progressive experience partnering with physicians

  • 10+ years’ experience working in risk bearing provider groups or health plan with population / medical management experience

  • 8+ years’ experience in clinical documentation

  • Prior operations experience in large, matrix healthcare environment

  • Strong knowledge of CMS Risk Adjustment and ICD - 9 / 10 coding requirements and regulations

  • Knowledge of federal and state laws and NCQA regulations relating to managed care and medical management


Preferred Qualifications:

  • Master’s degree in Healthcare Administration, Business Administration or a related field


Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)


*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.


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: Medical Directors, Clinical, Board Certified, Licensed, CMS Risk Adjustment, Texas

Job Details

  • Contest Number744915
  • Job TitleSr Medical Director, Payment Integriy-Claims Adjudication
  • Job FamilyMedical and Clinical Operations
  • Business SegmentOptumCare

Job Location Information

  • TX
    United States
    North America

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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