[Hiring] Medical Director @UnitedHealth Group

Role Description

This Medical Director role in the Clinical & Coding Advisory Team (CCAT) is a rare opportunity to work directly within Optum Payer Operations. As a member of CCAT, you will play a vital role in helping stop fraud, waste, abuse, and error, ensure correct payment of claims and help healthcare work better every day.

The purpose of the Optum Payment Integrity Medical Director is to provide expert clinical insight of provider claims. Key responsibilities include but are not limited to:

• Conducting clinical claim reviews
• Educating providers
• Managing high-level appeals
• Developing industry-leading clinical resources
• Driving operational improvements

This position serves as a forward-facing clinical expert within Optum, representing clinical strategy and payment integrity operations, and offering clinical and coding oversight across UnitedHealthcare and commercial clients. The role requires collaboration with valued clients and operational teams to ensure accurate claim payment, prevent fraud, waste, and abuse, and support ongoing enhancements in clinical and coding practice, aligned with UnitedHealth Group’s dedication to helping people live their lives to the fullest.

You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Provide expert clinical and strategic leadership for operational teams
• Collaborate and support clinical operations teams on complex cases
• Apply clinical and medical coding knowledge in the interpretation of medical policy, clinical resources, and benefit document language in the review of professional claims, itemized bills, and facility, pre-pay and post-pay clinical reviews
• Collaborate and educate network and non-network providers on cases and clinical coding situations in pursuit of accurate billing practices
• Actively participate in regular meetings and projects focused on clinical claim decision-making, clinical resources, analytics, savings, and staff training
• Participate in development of medical policy, clinical resources, and guidelines utilized in the review of professional and facility pre-pay and post-pay clinical reviews
• Other duties and goals assigned by the Senior Medical Director

Critical Success Factors:

• Ability to effectively lead, manage and deliver in a fast pace, dynamic environment
• Solid understanding of Fraud, Waste, Abuse, and Error methodology
• Ability to foster communications, robust collaboration, and strong partnerships among providers, clients, leaders, and clinical teams
• Solid problem-solving, negotiation and persuasion skills
• Excellent verbal and written communications skills in one-on-one and group settings

Qualifications

• Current, active, and fully non-restricted licensed MD or DO physician
• 5+ years of clinical practice experience
• 2+ years of experience in clinical operations within a health plan/or managed care environment to include client facing experience
• Thorough knowledge of CPT/HCPCS/ICD-10 coding, the health insurance business, and knowledge of industry terminology and regulatory guidelines
• Familiarity with current medical issues and practices

Requirements

• 3+ years in facility (DRG and Clinical Validation Audit) Reviews
• Coding Certification with AHIMA (CCS, CDIS, RHIA, RHIT) or AAPC (CIC, CPC)
• Experience with appeals and peer-to-peer conversations
• Experience in managing claims related to Fraud, Waste, Abuse and Error
• Experience with Encoder and Grouper Software (3M)
• Knowledge of federal (e.g., CMS) and state laws and regulations

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

Application Deadline

This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.