Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably. There is no room for error. If you are looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm)
This position 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 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 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. Position may serve as a liaison between OrthoNet, physicians, and other medical service providers in selected situations.
You’ll enjoy the flexibility to telecommute* from anywhere within United States as you take on some tough challenges.
- 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
- Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers)
- Provide Clinical support for staff that conduct initial reviews; which could include consolations with NP’s or CM’s
- 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.
- Current, active and fully unrestricted Medical license in state of residence
- Current Board Certification in an ABMS or AOBMS specialty in orthopedic surgery
- 5+ years of clinical experience post residency in musculoskeletal/spine surgery
- Proficiency with computer skills and ability to learn new systems and software
- Excellent project management skills
- Solid data analysis and interpretation skills; ability to focus on key metrics
- Board certification in ABSS (American Board of Spine Surgery)
- 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
- Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
The 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 education, work experience, certifications, etc. 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.
*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.
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