Associate Medical Director | Focus on Patient Care with 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. Work with the Appeals unit 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. * 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. * Act as the Clinical Lead for Risk Adjustment and works collaboratively with the Risk Adjustment team and IPA leadership and physicians to improve the accuracy and completeness of coding and documentation (approximately 50- 60% dedicated time for risk adjustment efforts). * Collaborates and engages with the IPA physicians and practices in order to implement strategies to improve the completion rate of annual wellness visits. Collaborates with the Quality team and IPA physicians and practices to implement strategies to improve Quality STARs measures. * Participates in affordability strategies to include inpatient management, outpatient high risk management, site of service and specialty contracting opportunities. Assist with coverage of Medical Directors in areas of review and IDTC conferenc....
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Posted September 2, 2021