Associate Medical Director, Optum

Ontario, CA

full-time
Outpatient

Job Highlights

  • High Earning Potential
  • Area Is Warm Year-Round
  • Willing to Pay for Licensing
  • 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 October 28, 2021