M.D. Special Investigations Medical Review Team - Remote

At UnitedHealthcare, 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 better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

Work at home!

The Medical Director for UnitedHealthcare's Investigations Unit (UHC IU) is a valuable national leader for UnitedHealthcare. The Medical Director oversees a coding team, ensuring accurate and efficient healthcare payments, accurate appeal outcomes, and collaborates with clinical and coding teams across UnitedHealthcare and Optum, as well as UHG business leaders and stakeholders, to drive informed decision-making and optimize outcomes.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

• Oversee and perform medical record reviews of retrospective medical claims relative to fraud, waste and abuse to include all levels of complexity
• Have the ability to review/code a variety of medical records using CPT, HCPCS and ICD-10 codes for office, outpatient, inpatient, surgical, hospital ancillary, nursing facility, urgent care, ambulatory surgery center and other charges for physicians and other providers of professional billing
• Provide clinical oversight and guidance to UHC IU medical record review team and UHC IU investigative staff
• Serve as a resource and Subject Matter Expert for team members in the UHC IU
• Document medical review findings on a claim level and draft reports of findings, actions and outcomes to be relied on in investigations of fraud, waste, and abuse cases in accordance with policies, and regulatory and accreditation requirements
• Ensure compliance with the UnitedHealthcare (UHC) Fraud, Waste and Abuse policies and other federal/state regulations or contractual obligations
• Communicate with UnitedHealthcare investigative staff regarding coding/clinical rationales
• Supply all criteria that was relied on, supporting all recommendations for denial or modification of claim payment errors
• Serve as a clinical resource for team members in the UHC IU
• Support the UHC IU in their interactions with providers to explain review/ medical record review 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 when participating in organizational committees, projects, and task forces
• Develop quality audit practices to ensure UHC SIU's Medical Record Review Team is 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 certification approved by the American Board of Medical Specialties (ABMS/AOBMS)
• 5+ years of clinical practice experience
• Familiarity with current medical issues and practices
• Proficiency in performing medical record case reviews 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 solid critical thinking and analytic skills
• Proven ability to manage multiple competing priorities
• Demonstrated ability to communicate effectively, to include written and verbal forms of communication
• Proven data analysis and interpretation skills
• Proven excellent presentation skills for both clinical and non-clinical audiences
• Proven creative problem-solving skills
• Proven excellent computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet research skills
• Proven solid team player and team building skills

Preferred Qualifications:

• Coding certification (CPC, CCS, etc.)
• Knowledge and experience in health care fraud, waste, and abuse (FWA) investigations
• Broad knowledge and experience in state and federal regulatory FWA requirements

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base 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 comply with all 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 (all benefits are subject to eligibility requirements). No matter where or when you begin 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 UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe 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 experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, 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.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.