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Regional Medical Director, NAMM Optum - Ontario, CA

Company: UnitedHealth Group
Location: Riverside
Posted on: December 8, 2018

Job Description:

We at NAMM, a part of OptumCare, deliver a clearly differentiated level of outcome and service adherence. Come join our team and add to our bench strength as we execute on managed care 2.0 bringing together revenue optimization, appropriate utilization, unit cost management and strategic acquisitions. Quality care saves money without exception. Careers at OptumCare. We're on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. The Medical Director interacts with Physicians and IPA staff to ensure that patient needs are met in an efficient and medically appropriate manner in keeping with the quadruple aim. The Medical Director is responsible for the Medical Management functions that include vendor relations, utilization management and business development. In addition, this role provides clinician oversight for major program and functional areas within Medical Management. These include regulatory affairs, medical policy implementation and population management for Medicare, Commercial and Medicaid lines of business. The Medical Director is also responsible for working with physicians and other providers, especially PCMH practices, to improve the quality and efficiency of care in the network and integrate these providers into clinical initiatives that deliver on outcomes and member experience of care. Primary Responsibilities:

  • Works primarily with the physician community around issues of particular patients, balancing business and clinical concerns.
  • Provides limited utilization management for outpatient medical, surgical and pharmacy activity.
  • Participates in medical appeals activity. Reviews all 2nd-level overturned cases related to medical necessity/investigational issues in the context of potential medical policy updates.
  • Works with the Appeals area on appeals related to utilization management issues.
  • Provides medical leadership and physician advice to the quality management area with respect to quality improvement studies, quality improvement committees, primary care assessments (both office-site assessments and medical record document reviews).
  • Performs peer reviews on quality complaints, sentinel events, and quality-of-care referrals.
  • Serves as Physician Advisor for other areas within the company, including but not limited to Sales and Marketing, Underwriting, PHP, and Provider Services.
  • Provides medical leadership and advice for conformance with standards and guidelines for NCQA, URAC, state and federal regulators, and other accrediting bodies.
  • Acts as liaison for communication with physicians, hospitals, and other providers in the community.
  • Reviews customer service and claims inquiries.
    Required Qualifications:
    • Possess a current and unrestricted MD or DO license in California or have the ability to attain a California Medical license.
    • 5+ years of clinical practice in direct patient care experience
    • 5+ years of medical management or administrative experience in a managed care setting
    • Possess sufficient clinical knowledge to interact with the physician members of the IPA in all major medical specialties
    • A proven track record of quality leadership and exceptional teamwork in order to build and foster stellar working relationships in both Clinical and Operational departments
    • Board certification in their chosen specialty Preferred Qualifications:
      • Board Certified in Geriatrics
      • Prior experience working with clinical information technology systems
      • Public presentation skills
      • Excellent written and oral communication skills What's the first thing that happens when one of the most successful groups in Riverside County comes together with a global leader in health care? Opportunity. With NAMM joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity 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. Job Keywords: Medical Director, MD, DO, managed care, UM, Utilization Management, CM, Case Management, IPA, clinical informatics, Ontario, Riverside, San Bernardino, San Diego, CA

        Keywords: UnitedHealth Group, Riverside , Regional Medical Director, NAMM Optum - Ontario, CA, Executive , Riverside, California

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