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.
The Sr. Director and Lead Medical Director will be the clinical leader for the Optum Payment Integrity organization. This is a rare opportunity to work directly within Optum as the forward-facing clinical executive, responsible for clinical leadership with our valued clients, clinical strategy and operations leadership, as well as clinical and coding oversight across UHC and external Commercial Clients/Operations.
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 strategic leadership and direction for professional and facility operational teams onshore and globally
- Collaborate and support clinical and coding operations teams with UHC and Commercial clients on complex or difficult cases to ensure remediation is completed
- Apply deep clinical and coding knowledge in the interpretation of client’s medical policy, clinical resources, and benefit document language in the review of professional and facility pre-pay and post-pay clinical reviews
- Lead and manage a team of subject matter clinical, coding and operational experts who are enabled to provide end-to-end clinical support to Optum’s Payment Integrity organization
- Collaborate with and educate network and non-network providers and client network executives on clinical coding guidelines and situations in pursuit of accurate billing practices
- Engage with executive leaders across the enterprise to enable strategic visions around the future of Payment Integrity clinical and coding
- Actively participate in regular meetings and projects focused on clinical decision-making, clinical resources, analytics, savings, and staff training
- Drive development of medical policy, clinical resources, and guidelines utilized in the review of professional and facility pre-pay and post-pay clinical reviews in partnership with Operations, Root Cause, Network and Clinical Policy for our clients
- Create a team culture of iteration, collaboration, and process improvement striving for ongoing and consistent product improvement with the goal of market leading payment integrity services
- Participate in conferences nationwide to enable more robust engagement with external parties around clinical and coding policy
- Continue to iterate Coding and Clinical Center of excellence hub in the US with mini hubs in India, Philippines and Puerto Rico to ensure the skillset and guidance in those countries are following our policy and regulations
- Enable $4B Medical Cost Savings across Clinical Payment Integrity by ensuring all clinical and coding reviews are accurate and follow the most up to date guidelines to meet the yearly goals of the organization
- Partner and collaborate with the Issue Management/Root Cause resolution team to support executive level discussions with clients and providers, as well as provide clinical and operational expertise to identify and reduce rework year over year with the focus of ongoing reduction in provider abrasion
Critical Success Factors:
- Ability to effectively lead, manage and deliver in a fast pace, ever changing environment
- Solid understanding of Fraud, Waste, Abuse, and Error methodology
- Ability to foster communications, develop robust collaboration, and solid partnerships among providers, clients, leaders, and clinical teams
- Energetic problem-solving, negotiation and persuasion skills
- Solid Innovative thinking mindset
- Strategic vision for building a Payment Integrity Clinical and Coding Center of Excellence
Required Qualifications:
- Current, active, and fully non-restricted US licensed Medical Doctor
- 8+ years of clinical practice experience after completion of nationally recognized residency training
- 5+ years of experience in leading clinical operations within a health plan or managed care environment, to include client facing experience
- 5+ years of experience working in/with health insurance business, including knowledge of industry terminology and regulatory guidelines
- 5+ years working with C suite level leaders and engaging familiarity with current medical issues and practices, including quality of care and standards of practice
Preferred Qualification: CPC Coding Certificate and/or CIC Coding Certificate with 2+ years of professional and/or facility coding experience
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.
