- Presentation Skills
- Medical License
- Microsoft Word
- Program Development
OrthoNet is a proud member of the UnitedHeath Group family of companies and a leading orthopedic specialty benefit management company. OrthoNet works with more than 80,000 orthopedic health care providers, including specialists in orthopedic surgery, neurosurgery, podiatry, and physical, occupational, and speech therapy. Our mission is to achieve optimal outcomes for payors, providers, and members in a manner that combines efficient delivery of services, high quality care, and state of the art utilization and cost management tools. Join our team and together we can ensure the delivery of high quality, cost-effective care for our members and customers.
As an important member of the FCR leadership team, the Senior Administrative Medical Director, reporting to the VP/Product Leader, will lead highly skilled multi-specialty Medical Director teams in the detailed comparative analysis of claims accuracy vs medical record notes. This is a unique opportunity to drive FCR forward by collaborating with Operations Leadership forming a cohesive team focused on providing innovative solutions and strategies, strong leadership and high quality results for all aspects of the clinical/coding review within the FCR product suite of payment integrity programs and services ring The Medical Director is expected to represent the programs he/she work on internally and to clients as needed, including during the sales and customer services activities.
Lead multi-specialty physician teams for OrthoNet’s growing family of payment integrity (Focused Claims Review) programs.
Oversee tactical execution of reviews ensuring all activities are completed within contractual guidelines including quality measures, turn-around-times and volume metrics
Oversee and develop claim guidelines continuing education and code updates, ensuring all MD results are consistent with high accuracy and detail
Expertise with professional procedure coding, claim reviews and appeal activity. Skilled at providing explanations of adverse decisions made on claims.
Strong interest in fraud and abuse detection and prevention
Committee and Administrative Leadership Responsibilities
Coordinate daily schedules of staff and consultant MDs ensuring a continuum of coverage for each specialty
Ensure high quality peer-to-peer coverage and content of discussions. Coordinate on-call schedules , aids in recruitment and professional development as appropriate
Manage day-to-day operations. Review and approve all staff out of office requests including vacation, CME, illness, LOA, etc. Perform annual quality and administrative staff reviews as required
Perform quality and quantity reviews, ensuring high quality performance and achievement of corporate goals
Serve on various internal and/or external Committees and in other such capacities as necessary
Assists with liaison relationships with payors and providers in the community as needed with regard to Payment Integrity
Serves as Lead contact with participating providers regarding payment integrity services and/or issues with OrthoNet MD activities. Supports other OrthoNet medical directors and staff within broader client base as needed as a professional, regulatory and community liaison
Supports compliance with regulatory agency standards and requirements (i.e. HCFA, NCQA, URAC, state/federal and third party payors)
Perform all other duties as assigned.
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.
M.D. or D.O. degree
Current and active Unrestricted, Medical license(s) in US state(s)
Board certification required in ABMS-recognized specialty
Minimum of 5 years’ post-graduate experience in clinical medical practice/patient care
Minimum of 2 years’ experience managing professional staff and leading teams of physicians
Minimum of 2 years’ experience in a managed care environment; to include coding and quality improvement experience
Must possess leadership skills in working with other physicians and non-physicians, knowledge of the overall medical community and the local/regional managed care environments
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.
Strong abilities and experience in large size health care organizations that are geographically widely distributed and heavily virtual (“remote workers”)
Demonstrated ability in developing and internally marketing concepts for program improvement and program development.
Ability and experience in relating to individuals at many levels of large organizations.
Experience in presenting/selling programs to potential clients.
Specific familiarity with managed care accreditation activities and NCQA, URAC, CMS, state and other federal regulations.
MS Office (MS Word, Excel, and Power Point)
Certifications: ABMS specialty preferably with musculoskeletal/orthopedic emphasis
Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. Bring your skills and talents to a role where you'll have the opportunity to make an impact on a huge scale. This is the place to do your life's best work.(sm)
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.
Keywords: Medical Director, Claims, ABMS, M.D., D.O., coding, quality improvement