8 days old

Claims Review Medical Director Neurosurgery

New York, NY 10007
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  • Job Code
    873394

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's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

 

As part of the Focus Claims Review team, the Medical Director provides leadership, organization, and direction for the claims review program. They are responsible for the overall quality, effectiveness and coordination of the medical services provided through OrthoNet. The Medical Director will participate in all aspects of claim review services including provider telephonic discussions and provider appeals.  In addition, the Medical Director may also be asked to assist 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
  • 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
  • Provide Clinical support for staff that conduct initial reviews
  • 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.

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Posted: 2020-05-16 Expires: 2020-06-15

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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Claims Review Medical Director Neurosurgery

UnitedHealth Group
New York, NY 10007

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