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Medical Director - General Surgery - Remote
Requisition number: 2360162
Job category: Medical & Clinical Operations
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 inclusion, talented peers, comprehensive benefits and career development opportunities.
Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs.
The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical Services.
The Medical
Director collaborates with Enterprise Clinical Services leadership and staff to establish, implement, support, and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members.
The Medical
Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well as other Enterprise Clinical Services.
The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member's primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that the appropriate and most cost-effective quality medical care is provided to members.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
- Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements
- Engage with requesting providers as needed in peer-to-peer discussions
- Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
- Participate in daily clinical rounds as requested
- Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
- Communicate and collaborate with other internal partners
- Call coverage rotation
Required Qualifications:
- M.D or D.O.
- Board certification in General Surgery through the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)
- Active unrestricted license to practice medicine
- 5 years of clinical practice experience after completing residency training
- Sound understanding of Evidence Based Medicine (EBM)
- Solid PC skills, specifically using MS Word, Outlook, and Excel
- Proven ability to participate in call coverage rotation
- Experience in utilization and clinical coverage review
- Proven excellent oral, written, and interpersonal communication skills, facilitation skills
- Proven data analysis and interpretation aptitude
- Proven innovative problem-solving skills
- Proven excellent skills for both clinical and non-clinical audiences
- Reside in either MST or PST zone or willing to work those hours
