Uhc Careers – UM Medical Director

Website United Healthcare

Job Description:

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. Position may serve as a liaison between OrthoNet, physicians, and other medical service providers in selected situations.

Job Responsibilities:

  • Good understanding of professional performance measurement and related possible discussions/interventions with selected providers/groups/organizations
  • Performs utilization management reviews for various types of musculoskeletal and other medical/surgical services which may include PT OT ST, home health care, SNF, LTAC and acute inpatient rehabilitation services
  • Composes, if needed, patient situation specific, clinical summaries and rationales for medical necessity decisions
  • Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews
  • Provide Clinical support for staff that conduct initial reviews; which could include consolations with NP’s or CM’s
  • Works with Ortho Net clinical staff to coordinate all the necessary UM processes and provides feedback to OrthoNet staff who do portions of the UM reviews
  • Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third-party payers)
  • Discusses cases and clinical situations with treating providers telephonically during scheduled hours
  • Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable

Job Requirements:

  • Proficiency with computer skills and ability to learn new systems and software
  • Current, active and fully unrestricted Medical license in state of residence
  • Solid data analysis and interpretation skills; ability to focus on key metrics
  • Board certification in ABSS (American Board of Spine Surgery)
  • Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
  • Excellent project management skills

Qualification & Experience:

  • 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
  • Current Board Certification in an ABMS or AOBMS specialty in orthopedic surgery
  • 5+ years of clinical experience post residency in musculoskeletal/spine surgery

Job Details:

Company: United Healthcare

Vacancy Type: Full Time

Job Location: Tri-Cities, AL, US

Application Deadline: N/A

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