Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Optum is currently seeking a Short Stay Billing Validation (SSBV) Medical Director to join our Clinical and Coding Audit (CCAT) team with Optum Insights. This team is responsible for conducting facility inpatient payment integrity audits addressing ambulatory or outpatient hospital encounters that are incorrectly billed as inpatient. The SSBV Medical Directors work with cross-functional clinical reviews of nurses and do not question the severity of a patient's condition, nor the necessity of the care provided. Instead, Short-Stay Billing Validation determines whether the care provided was billed correctly. Optum's SSBV Medical Directors are part of a national organization and team, and collaborate with peers, nurse managers, and non-clinical employees from across the country.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Provide physician-level review and determination of short-stay inpatient claims to ensure accurate billing status and alignment with evidence-based guidelines
- Support audit integrity by delivering clear, defensible clinical rationale and partnering with clinical and operational teams to drive consistent review outcomes
- Grounded in the use and application of evidence-based medicine (EBM) such as InterQual®
- Responsible for collaborating with operational and business partners
- Maintain proficiency in all required software and platforms
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 medical license in the U.S
- Board certification up-to-date and in good standing
- Current Board Certification in an ABMS or AOBMS specialty
- 3+ years of clinical practice experience
- Technical proficiency in computer software and systems
- Proven ability to work collaboratively with nurses, coders, and operational partners in a matrixed environment
- Demonstrated excellence with both written and oral communication skills across clinical and non-clinical audiences
Preferred Qualifications:
- 2+ years of managed care, Quality Management experience and/or administrative leadership experience
- Experience applying evidence-based level-of-care criteria (e.g., InterQual® or MCG) in utilization review or payment integrity settings
- Experience with short-stay billing validation, inpatient status review, or physician advisory services in the acute care setting
- Experience developing clear, well-supported clinical rationale for billing status determinations and audit findings
- Knowledge of CMS guidelines, medical necessity review principles, and payer audit processes
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. 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. The salary for this role will range from $248,500 - $373,000 annually based on full-time employment. We comply with all minimum wage laws as applicable."
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.