Senior Medical Director for UnitedHealthcare Payment Integrity - Remote
: Job Details :

Oversee and perform individual case review for facility appeals for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations of facility clinical validation audits for medical services and the application of clinical criteria of medical policies Provide clinical oversight and guidance to UHC 3rd party vendors engaged in clinical payment integrity reviews Perform Department of Insurance/ Department of Managed Healthcare, and CMS regulatory and IRE responses Oversee the Independent Review Organization Process Document clinical validation audit findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements Communicate with UnitedHealthcare medical directors regarding coding/clinical validation appeals rationales Communicate with UnitedHealthcare Regional and Plan medical directors and network management staff regarding clinical payment integrity reviews/audi...Medical Director, Healthcare, Director, Payment, Health, Medical