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Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

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 and help healthcare work better every day.

The purpose of this job is to help people live their lives to the fullest by providing clinical leadership and expertise for the clinical investigation teams, including involvement in clinical reviews, provider education, high level appeals, development of clinical resources, and operations improvements.

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 with clinical operations teams on complex or difficult cases

• Apply clinical knowledge in the interpretation of medical policy, clinical resources, and benefit document language in the review of professional and facility pre-pay and post-pay clinical reviews

• Collaborate with 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 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 Sr. Medical Director

Critical Success Factors:

• Ability to effective lead, manage and deliver in a fast pace, ever changing environment

• Solid understanding of Fraud, Waste, Abuse, and Error methodology

• Ability to foster communications, robust collaboration, and solid partnerships among providers, clients, leaders, and clinical teams

• Solid problem-solving, negotiation and persuasion skills

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.

Required Qualifications:

• Current, active, and fully non-restricted licensed Medical Doctor

• 5+ years of clinical practice experience

• 2+ years of experience in leading clinical operations within a health plan/or managed care environment to include client facing experience

• CPT/HCPCS/ICD-9/ICD-10 coding experience with a thorough knowledge of health insurance business, including knowledge of industry terminology and regulatory guidelines

• Familiarity with current medical issues and practices

Preferred Qualifications:

• Coding Certification thru AHIMA (CCS, CDIS, RHIA, RHIT) or AAPC (CIC)

• 3+ years in facility (DRG and Clinical Validation Audit) Reviews

• Experience in claims handling 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

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

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.