The OrthoNet Senior Medical Director, Utilization Management provides leadership, organization, and direction for all utilization management programs and other Medical Services Department activities as applicable. Responsible for the overall quality, effectiveness and coordination of the utilization management programs and other managed care services provided through OrthoNet/Optum.
Oversees the Utilization Management program and associated Medical Directors for the company/business unit, will supervise the monitoring of utilization management and all other applicable managed care health services activities. This role provides direction and assists in the development and implementation of clinical and administrative policies and procedures and any needed clinical criteria for all medical programs and services that are part of the Company's programs. He/she will serve as the primary liaison between OrthoNet and client Medical Directors; and OrthoNet and other medical service providers with whom we interact with for health services and managed care programs.
You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges
Utilization Management, Health Services Delivery and other Managed Care Programs
- Lead physician for OrthoNet's Utilization Management programs. Coordinates activities of OrthoNet physicians and MD consultants assigned to Utilization Management activities.
- Leads efforts to ensure consistency of clinical decision-making, assures all MDs are aware of current client and OrthoNet clinical criteria, assures high quality peer-to-peer coverage and content of discussions, coordinates on staff schedules and aids in recruitment and professional development as appropriate to OrthoNet roles
- Serves as, directed by the Chief Medical Officer or Chief Executive Officer, on various internal and/or external Committees and in other such capacities
- Monitors all relevant reports, information summaries, clinical and financial data relating to these activities and works with senior management to further improve overall company performance
- Provides direction for development and implementation of new utilization management, population health, provider and member integrated health care operations and other activities
- Participates in the development and implementation of policies and procedures to ensure effective monitoring and management of managed care activities Participation in Training regarding URAC, NCQA, CMS and other Regulatory Compliance. Represents OrthoNet in broader company activities and program development as required. Provides consultative guidance, as needed, for programs in payment integrity and professional/other services claim coding. Chairs/Serves on utilization management
Medical Services and Provider Services
- Assists the Provider Relations, customer service and other staff with resolving provider and payor issues including, but not limited to clinical inquiries, claims issues, fee schedule concerns, medical policies, procedures and member/provider appeal coordination
- Through the Manager, UM/ Administrative Operations, oversees the non-clinical support operations of the Medical Services Department
- Maintains liaison relationships with payors and providers in the community as required
- Serves as the primary physician contact with clients/managed care clients and participating providers regarding OrthoNet [UM related] activities
- Represents OrthoNet as required in other company business
- Monitors compliance with regulatory agency standards and requirements (i.e. CMS, NCQA,URAC, state/federal and third party payors)
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
- Board certification in an ABMS surgical specialty
- Minimum of 5 years' post-graduate experience in clinical medical practice/patient care
- 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 quality improvement, utilization management and case management 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 care providers.
- Specific familiarity with managed care accreditation activities and NCQA, URAC, CMS, state and other federal regulations.
- MS Office (MS Word, Excel, and Power Point)
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy
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, Utilization Management, Telecommute, Manager, Leadership, Managed Care, Surgery, Surgical, Physician