CCAT Medical Director - Remote

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization 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, 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, and 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
  

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 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
  

Preferred Qualifications:

• 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

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

Compensation for this specialty generally ranges from $248,500.00 to $373,000.00. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer 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 us, 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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.