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Claims Review Medical Director Cardiovascular Surgery

Company: Optum
Location: White Plains
Posted on: February 16, 2020

Job Description:

Surgery-General opening in White Plains, New York. This and other physician jobs brought to you by DocCafe.com 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 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. Required Qualification
    • Current, active and fully unrestricted Medical license
    • Board certified in an ABMS specialty
    • 5+ years clinical experience post residency with Sub-Specialty training in Cardiovascular surgery
    • Use and knowledge of coding and billing practices
    • Proficient computer skills to include MS Office (MS Word, Excel, and Power Point)
    • Ability to learn to use OrthoNet clinical and claims software
    • Must be able to work Eastern Standard Time hours
      Preferred Qualifications:
    • Experience in managed care
    • Prior experience with professional claim coding resources / claim coding reviews and techniques strongly preferred
    • Exhibits leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments
    • 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
      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. Keywords: Medical Director, Vascular, Cardiovascular, Surgery, New York, New Jersey, Pennsylvania, Connecticut, board certified, claims Keyphrases: general surgery jobs, surgery jobs, surgeon jobs, general surgeon jobs, cardiovascular thoracic surgery jobs, cardiovascular thoracic surgeon jobs, thoracic cardiovascular surgery jobs, thoracic cardiovascular surgeon jobs, thoracic and cardiovascular surgeon jobs, thoracic and cardiovascular surgery jobs, colo rectal surgeon jobs, colo rectal surgery jobs, neuro surgeon jobs, neuro surgery jobs, oral plastic surgery jobs, oral plastic surgeon jobs, pediatric oral surgery jobs, pediatric oral surgeon jobs, dental oral surgery jobs, dentist oral surgeon jobs, dentist oral surgery jobs, maxillofacial oral surgeon jobs, maxillofacial oral surgery jobs, oral maxillofacial surgeon jobs, oral maxillofacial surgery jobs, cardio thoracic surgery jobs, cardio thoracic surgeon jobs, cardio vascular surgeon jobs, pediatric vascular surgeon jobs, pediatric vascular surgery jobs, surg tech jobs, surgery tech jobs, surgical tech jobs, gynecologic surgery jobs, surgical jobs

Keywords: Optum, White Plains , Claims Review Medical Director Cardiovascular Surgery, Executive , White Plains, New York

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