1+ months

Senior Administrative Medical Director Focused Claims Review

White Plains, NY 10601
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OrthoNet is a proud member of the UnitedHeath Group family of companies and a leading orthopedic specialty benefit management company. OrthoNet works with more than 80,000 orthopedic health care providers, including specialists in orthopedic surgery, neurosurgery, podiatry, and physical, occupational, and speech therapy. Our mission is to achieve optimal outcomes for payors, providers, and members in a manner that combines efficient delivery of services, high quality care, and state of the art utilization and cost management tools. Join our team and together we can ensure the delivery of high quality, cost-effective care for our members and customers.


As an important member of the FCR leadership team, the Senior Administrative Medical Director, reporting to the VP/Product Leader, will lead highly skilled multi-specialty Medical Director teams in the detailed comparative analysis of claims accuracy vs medical record notes.  This is a unique opportunity to drive FCR forward by collaborating with Operations Leadership forming a cohesive team focused on providing innovative solutions and strategies, strong leadership and high quality results for all aspects of the clinical/coding review within the FCR product suite of payment integrity programs and services ring The Medical Director is expected to represent the programs he/she work on internally and to clients as needed, including during the sales and customer services activities.


Primary Responsibilities:


Payment Integrity

  • Lead multi-specialty physician teams for OrthoNet's growing family of payment integrity (Focused Claims Review) programs.
  • Oversee tactical execution of reviews ensuring all activities are completed within contractual guidelines including quality measures, turn-around-times and volume metrics
  • Oversee and develop claim guidelines continuing education and code updates, ensuring all MD results are consistent with high accuracy and detail
  • Expertise with professional procedure coding, claim reviews and appeal activity.  Skilled at providing explanations of adverse decisions made on claims.
  • Strong interest in fraud and abuse detection and prevention


Committee and Administrative Leadership Responsibilities

  • Coordinate daily schedules of staff and consultant MDs ensuring a continuum of coverage for each specialty
  • Ensure high quality peer-to-peer coverage and content of discussions.  Coordinate on-call schedules  , aids in recruitment and professional development as appropriate
  • Manage day-to-day operations.  Review and approve all staff out of office requests including vacation, CME, illness, LOA, etc.  Perform annual quality and administrative staff reviews as required
  • Perform quality and quantity reviews, ensuring high quality performance and achievement of corporate goals
  • Serve on various internal and/or external Committees and in other such capacities as necessary


Liaison Activities

  • Assists with liaison relationships with payors and providers in the community as needed with regard to Payment Integrity
  • Serves as Lead contact with participating providers regarding payment integrity services and/or issues with OrthoNet MD activities.  Supports other OrthoNet medical directors and staff within broader client base as needed as a professional, regulatory and community liaison


Regulatory Requirements

  • Supports compliance with regulatory agency standards and requirements (i.e. HCFA, NCQA, URAC, state/federal and third party payors)
  • Perform all other duties as assigned.


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.

Posted: 2020-01-01 Expires: 2020-03-31

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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Senior Administrative Medical Director Focused Claims Review

UnitedHealth Group
White Plains, NY 10601

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