Description
We at NAMM, a part of OptumCare, deliver a clearly differentiated level of outcome and service adherence. Come join our team ad 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 anefficient and medically appropriate manner. The Medical Director of is responsible for the Medical Management functions that include vendor relations, Utilization Management and business development. In addition, this role provides prime management, oversight and development for major program and functional areas within Medical Management. These include medical policy, patient centered medical home, Medicaid, Health and Wellness, population management, and reporting capabilities. 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. 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
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.
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