Associate Medical Director, Optum
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.
Posted July 10, 2021