Senior Administrative Medical Director Focused Claims Review
M Senior Administrative Medical Director Focused Claims Review
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
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.
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
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
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
Supports compliance with regulatory agency standards and
requirements (i.e. HCFA, NCQA, URAC, state/federal and third party
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.
M.D. or D.O. degree
Current and active Unrestricted, Medical license(s) in US
Board certification required in ABMS-recognized specialty
Minimum of 5 years' post-graduate experience in clinical medical
Minimum of 2 years' experience managing professional staff and
leading teams of physicians
Minimum of 2 years' experience in a managed care environment; to
include coding and quality improvement experience
Must possess leadership skills in working with other physicians
and non-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
Strong abilities and experience in large size health care
organizations that are geographically widely distributed and
heavily virtual ("remote workers")
Demonstrated ability in developing and internally marketing
concepts for program improvement and program development.
Ability and experience in relating to individuals at many levels
of large organizations.
Experience in presenting/selling programs to potential
Specific familiarity with managed care accreditation activities
and NCQA, URAC, CMS, state and other federal regulations.
MS Office (MS Word, Excel, and Power Point)
Certifications: ABMS specialty preferably with
Challenge brings out the best in us. It also attracts the best.
That's why you'll find some of the most amazingly talented people
in health care here. Bring your skills and talents to a role where
you'll have the opportunity to make an impact on a huge scale. This
is the place to do your life's best work.(sm)
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, Claims, ABMS, M.D., D.O., coding,
Associated topics: care, care physician, clinic, family medicine
physician, family practice physician, hospitalist, nocturnist,
physician md, practice physician, primary care
Job ID: ba5122c0-12126671581
White Plains, New York, United States
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