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 Medical Director Orthopedic Surgery - New York, New York, United States

Job information
Posted by: United HealthCare Group 
Hiring entity type: Health and Medical Svcs. 
Work authorization: Existing work authorization required for United States
Position type: Direct Hire, Full-Time 
Compensation: ******
Benefits: 401(k) -
Health Insurance -
Paid Vacation -
Relocation: No relocation assistance provided 
Position functions: Health - Physician
Travel: Minimal 
Accept candidates: in same country 
Languages: English - Fluent
Minimum education: Doctorate 
Minimum years experience:
Resumes accepted in: English
Cover letter: No cover letter requested
Virtual interview questions: No questions which require answers when applying for this job posting.
Job code: 882841 / Latpro-3762893 
Date posted: Nov-20-2020
State, Zip: New York, 10601


Claims Review Medical Director Orthopedic Surgery
Telecommute from home role - can live anywhere in the Eastern Time Zone

Position Description
As part of the Focus Claims Review team, the Medical Director provides leadership, organization, and direction for the claims review program. They are responsible for the overall quality, effectiveness and coordination of the medical services provided through OrthoNet. The Medical Director will participate in all aspects of claim review services including provider telephonic discussions and provider appeals.  In addition, the Medical Director may also be asked to assist in the direction and oversight in the development and implementation of policies and procedures and clinical criteria for all medical programs and services.  S/he will serve as a liaison between OrthoNet, physicians, and other medical service providers in selected situations primarily related to medical claim reviews.  
You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities: 
· Reviews surgical and other professional claims for correct coding using clinical record  
· Participation 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 
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 unrestricted Medical license
· Board certified in an ABMS specialty
· 5+ years clinical experience in Orthopedic Surgery post residency with training in Spine, Hand, Joint and/or Sport
· Use and knowledge of coding and billing practices
· Proficient computer skills to include MS Office (MS Word, Excel, and Power Point)
· Must be able to work Eastern Standard Time hours