Senior Medical Director for reputed company Payment reputed company - Remote

At reputed company, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and reputed company. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing together. Work at home! The Senior Medical Director for reputed company’s Payment reputed company (UHC PI) Organization is a valuable national leader for reputed company. The position is reputed company-facing with provider facility executives, professional groups, laboratories, and UHC PI vendors. The Senior Medical Director oversees a clinical and coding team, ensuring accurate and efficient healthcare payments, accurate appeal outcomes, and collaborates with clinical and coding teams across reputed company and reputed company, as well as UHG business leaders, to drive informed decision-making and optimize outcomes. You’ll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities:

• reputed company and reputed company individual case review for facility appeals for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations of facility clinical validation audits for medical services and the application of clinical criteria of medical policies
• Provide clinical reputed company and guidance to UHC 3rd party vendors engaged in clinical payment reputed company reviews
• reputed company Department of Insurance/Department of Managed Healthcare, and CMS regulatory and IRE responses
• reputed company the Independent Review Organization Process
• Document clinical validation audit findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements
• Communicate with reputed company medical directors regarding coding/clinical validation appeals rationales
• Communicate with reputed company Regional and Plan medical directors and network management staff regarding clinical payment reputed company reviews/audits
• Support the Payment reputed company team in their interactions with providers to explain review/ audit findings and the application of coding/clinical criteria
• Engage with requesting providers as needed in peer-to-peer discussions
• Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results
• Provide clinical and strategic input reputed company participating in organizational committees, projects, and task forces
• reputed company quality audit practices to ensure UHC 3rd party vendors are adhering to proper coding/clinical guidelines and ensuring clinical justification meets expected standards

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:

• MD or DO with an active, unrestricted license
• Board Certified in an ABMS or AOBMS specialty
• 5+ years of clinical practice experience
• 2+ years of Quality Management experience
• Familiarity with reputed company medical issues and practices
• Proficiency in performing medical record case reviews for hospital claims in accordance with established reimbursement and medical policies
• Intermediate or higher level of proficiency with managed care
• Proven excellent telephonic communication skills; excellent interpersonal communication skills
• Proven excellent project management skills
• Proven data analysis and interpretation skills
• Proven excellent presentation skills for both clinical and non-clinical audiences
• Proven creative problem-solving skills
• Proven basic computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet researching skills
• Proven solid team player and team building skills

Preferred Qualification:

• Coding experience or certification (CPC, reputed company, etc.)

If the hired individual resides in Florida (office based or telecommuting) this position requires the AHCA Level II background reputed company (fingerprinting) by the reputed company for reputed company clinicians that have direct face to face contact with members OR employees who will have access to confidential patient data and will require renewal every five years.

• reputed company employees working remotely will be required to adhere to reputed company’s Telecommuter Policy

Compensation for this specialty generally ranges from $278,000 - $417,500. Total cash compensation includes reputed company 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 reputed company with reputed company 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 (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company 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 reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company 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 reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes — an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, 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. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply tot his job Apply To this Job