[Hiring] Medical Director - Orthopedic Spine, Neurosurgery or Spine Surgery @UnitedHealth Group

Role Description

Position in this function is responsible, in part, as a member of a team of medical directors, for the overall quality, effectiveness and coordination of the medical review services. Additionally, performs Utilization Management reviews and directs/coordinates aspects of the utilization review staff activities, and participates in the Quality Improvement programs for the company.

The Medical Director also provides/assists in the direction and oversight in the development and implementation of policies, procedures and clinical criteria for all medical programs and services and may serve as a liaison between physicians, and other medical service providers in selected situations.

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

Primary Responsibilities:

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations.
• The focus of the coverage reviews will be various types of musculoskeletal and other medical/surgical services which will include prior authorizations for spine surgery.
• Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements.
• Support compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers).
• Work with clinical staff to coordinate all the necessary coverage reviews and provide feedback to staff who do portions of the coverage reviews.
• Engage with requesting providers as needed in peer-to-peer discussions.
• Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews.
• Participate in periodic clinical conferences / calls and in ongoing internal performance consistency reviews.
• Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy.
• Communicate and collaborate with other internal partners.
• Call coverage rotation. Is available for periodic weekend and holiday coverage as needed for telephonic and remote computer expedited clinical decisions.
• Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable.
• Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations.

Qualifications

• Current, active and unrestricted medical license.
• Current Board Certification in Orthopedic Surgery or Neurosurgery.
• 5+ years clinical experience post residency in Orthopedic Surgery or Neurosurgery to include experience with musculoskeletal/ spine surgery.
• Sound understanding of Evidence Based Medicine (EBM).
• Proficient with MS Office (MS Word, Email, Excel, and Power Point).
• Excellent computer skills and ability to learn new systems and software.
• Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel.
• Willing to obtain additional licenses as needed.

Requirements

• Active license in South Carolina, Minnesota or Texas, but candidates with an active license in other states are acceptable.
• ABMS or other nationally recognized further specialized certifications.
• Experience in managed care UM activities/ coverage reviews.
• 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.
• Possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments.

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.