Payment Integrity Medical Director - WellMed Medical Group - Remote

Company: Optum
Location: San Antonio
Posted on: May 19, 2025

Job Description:

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.
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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. They will communicate with appropriate parties, including but not limited to providers, vendors, and health plans regarding appeals, grievances and provider reconsideration requests. This individual will assist analyze and identify trends to address root causes and eliminate rework that is costly in terms of both dollars and working relationships. This role may research and resolve claims-related written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians/providers.
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The Medical Director will work to assist in the development and maintenance of relevant algorithms and methodologies to sustain a claims anomaly surveillance system; identify trends, outliers of concern, and improvement opportunities. They will be responsible for investigating and resolving all types of claim aberrancies as well as recovery and resolution for health plans, commercial customers, and government entities. This role will also review claims and medical documentation for medical necessity for claims CPT code usage, and for edits set for reviews by Claims and Payment Integrity team.
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You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
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Primary Responsibilities: -

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• 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
  
  Personal and Physician Development:
  
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  • Strives to personally expand working knowledge of all aspects of the Payment Integrity leadership
    
  • An active participant in physician meetings
    
  • Assists in the growth and development of subordinates by sharing special knowledge with others and promotes continued education classes
    
  • Attends continuing education classes to keep abreast of fraud trends, medical advancements and innovative practice guidelines
    
    What makes an Optum organization different?
    
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    • Be part of best-in-class employee experience that enables you to practice at the top of your license
      
    • We believe that better care for clinicians equates to better care for patients
      
    • We are influencing change collectively on a national scale while still maintaining the culture and community of our local care organizations
      
    • Practice medicine autonomously, with the support, not restrictions, of a sustainable and thriving national health care organization
      
      Compensation/Benefits Highlights:
      
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      • Base Salary plus bonus -
        
      • Financial stability and support of a Fortune 5 Company
        
      • Robust retirement offerings including employer funded contributions and Employee Stock Purchase Plan (ESPP for UHG Stock)
        
      • Comprehensive Benefits plan inclusive of medical, dental, vision, STD/LTD, CME and malpractice
        
      • Robust clinician learning and development programs -
        
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        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:
        
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        • 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
          
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          Preferred Qualifications:
          
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          • 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
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            *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
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            The salary range for this role is $238,000 to $357,500 per year. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
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            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.
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            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.
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            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.
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            UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: Optum, Round Rock , Payment Integrity Medical Director - WellMed Medical Group - Remote, Executive , San Antonio, Texas