Job Description

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.

Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, 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 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 and may serve as a liaison between physicians, and other medical service providers in selected situations.

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

Primary Responsibilities:

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations. The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for spine surgery
Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers)
Works with clinical staff to coordinate all the necessary UM processes and provides feedback to 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
Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
Participate in rotational call coverage. Is available for occasional, periodic weekend and holiday as needed telephonic and remote computer expedited clinical decisions
Provide Clinical support for staff that conduct initial reviews
Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable. Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations

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:

Current, active, and fully unrestricted medical license
Current Board Certification and must maintain Board Certification in Orthopedic Surgery
5+ years clinical experience post residency in Orthopedic Surgery
Proficient with MS Office (MS Word, Email, Excel, and Power Point)
Proven excellent computer skills and ability to learn new systems and software
Proven excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
Proven ability to participate in rotational call coverage
Willing and ability to obtain additional medical licenses as needed

Preferred Qualifications:

License in North Carolina or New Mexico a plus
Experience in managed care UM activities
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
Proven leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments

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

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, 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.

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.