Payment Integrity Medical Director - WellMed Medical Group - Remote

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.

The Medical Director, Payment Integrity is responsible for providing expertise and general support to teams in reviewing, researching, investigating, negotiating and resolving all types of aberrant claims and utilization issues.

Primary Responsibilities:

• Develop and grow strong partnerships with regional medical directors and local physician champions to execute on enterprise strategy and objectives
• Assist Senior Medical Director to identify from claims data best and worst practices and resources by market, and share in actionable form the opportunities that Regional and Market Medical and Business Leadership and Network Contracting might productively address
• Work with Regional Leadership to develop and implement best practices and consistent process/tools across WellMed
• Partners with leadership team to coordinate provider mentoring/education regarding referral management, wise utilization, and fraud and waste reduction program components
• Forms internal and external strategic relationships which will support program innovation, growth, expansion and the development of new programs
• Directs others to resolve business problems that affect multiple functions or disciplines
• Develops, translates and executes strategies or functional/operational objectives for a region, line of business, or major portion of a business segment functional area
• Directs others to resolve highly complex or unusual business problems that affect major functions or disciplines
• Develops, translates and executes strategies or functional and operational objectives at the business unit, multiple markets/sites and segment level

Required Qualifications:

• Active, unrestricted MD/DO license
• Board Certified in a Medical Sub-Specialty
• 8+ years of experience in clinical documentation
• 5+ years of clinical practice experience
• 3+ years of experience with Claims oversight, Special Investigations, or anti-fraud and waste programs, CMS Program Integrity functions, or with Utilization oversight using claims data
• 3+ years of experience with CMS Appeals and Payment Integrity Manual (PIM) regulations and process
• 3+ years of experience working in risk bearing provider groups or health plan with population/medical management experience
• 2+ years of experience with CMS Medicare Administrative Contractor (MAC) as medical director with experience with CMS Program Integrity and work with NCD, LCD and Articles, along with NCCI edits and Appeals processes
• Operations experience in large, matrix healthcare environment
• Working knowledge of CMS claims processing and payment requirements & regulations
• Knowledge of federal and state laws and NCQA regulations relating to managed care and medical management
• Proficiency with Microsoft Office applications

Preferred Qualifications:

• 3+ years of experience with CMS Medicare Administrative Contractor (MAC) as medical director with experience with CMS Program Integrity and work with NCD, LCD and Articles, along with NCCI edits and Appeals processes

About Optum

Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare. We’re a global organization that’s evolving health care so everyone can have the opportunity to live their healthiest life. With our hands across all aspects of health, we'll provide you with a rewarding career that enables you to grow in the directions that best fit your passions. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together.