Medical Director Plastic Surgery Leader

hace 4 semanas

Guayacán Barrio, Puerto Rico Unitedhealth Group A tiempo completo
Medical Director Plastic Surgery Opportunity

UnitedHealth Group is a global organization that delivers care, aided by technology to help millions of people live healthier lives. As a Medical Director Plastic Surgery, you will play a crucial role in improving health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.

The Medical Director Plastic Surgery will provide leadership, organization, and direction for the claims review program. They will be responsible for the overall quality, effectiveness and coordination of the medical services provided through Optum. The Medical Director will participate in all aspects of claim review services including provider telephonic discussions and provider appeals.

Key Responsibilities:

  • Reviews surgical and other professional claims for correct coding using clinical record
  • Participates 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

Requirements:

  • MD or DO
  • Current, active, and fully unrestricted medical license
  • Current board certification in Plastic Surgery
  • 5+ years of clinical experience post residency in Plastic Surgery; to include head and neck surgery
  • MS Office (MS Word, Excel, and Power Point)

Preferred Qualifications:

  • Experience in managed care
  • Experience with professional claim coding / claim coding 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
  • Knowledge of claim coding resources and techniques
  • Proficient computer skills and ability to learn to use clinical and claims software
  • Proven excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel

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.

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