Physician Advisor - Concurrent Appeals & Denials - Remote

UnitedHealth Group; Newtown Square (Delaware County); Remote; USD 160,000 - 300,000; Full time

Job summary

UnitedHealth Group is seeking a Physician Advisor to partner with providers, case managers, and payors for medical necessity reviews and appeals. You will conduct concurrent peer-to-peer discussions and ensure appropriate patient status determinations across client health systems.

Role emphasizes clinical expertise to support quality outcomes, regulatory compliance, and cost-effective care with remote work within the U.S. Optum Insight functions are highlighted in the role.

Qualifications

• Licensed Physician (MD or DO) with a current, active, unrestricted Medical License in the U.S.
• Current Board Certification
• 3+ years of experience in a hospital-based practice setting
• Demonstrated computer proficiency (MS Office, etc.)
• Willing to work evenings/weekends/holidays as needed
• Willing to work at least 3 holidays per year

Responsibilities

• Provide medical necessity and compliance reviews for client hospitals
• Perform concurrent peer-to-peer reviews with payor medical directors
• Conduct written and verbal appeals
• Support timely, appropriate and cost-effective patient status determinations
• Engage with team members across Physicians Advisors, Nurses, and Administrative staff

Skills

US MD/DO license

Board Certification

MS Office

Education

MD or DO degree

Tools

MS Office

Job description

OptumInsightis improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, andultimately consumers. Our deepexpertisein the industry and innovative technology empower us to help organizations reduce costs while improving risk management,qualityand revenue growth. Ready to help us deliver results that improve lives?Join us to start Caring. Connecting. Growing together.

In this Physician Advisor role, you will partner with providers, case managers, and payors to conduct medical necessity reviews, facilitate peer-to-peer discussions, manage appeals, and ensure appropriate patient status determinations. This position offers the opportunity to leverage your clinical expertise to support quality outcomes, compliance, and cost-effective care across client health systems.

Basic Functions:

• To provide medical necessity and compliance reviews for our client hospitals
• To perform concurrent peer to peer reviews with payor medical directors
• To perform written and verbal appeals

Hours

Coverage spans from 8am-3am EST with set schedules based on business needs providing adequate staffing for all shifts. There is a shared responsibility for weekend and Holiday coverage by all Physician Advisors.

You'llenjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Promote efficient and effective clinical care of hospitalized patients delivered in a timely, appropriate and cost-effective fashion as guided by evidenced based medicine and regulatory requirements via review of clinical documentation, collaborative telephonic communication and other interactions with hospital client Case Managers and Attending Physicians
• Promote payor and provider adherence to all applicable regulatory standards and CMS policy regarding inpatient admissions, observation/outpatient status, and the appropriate status for continued hospital stays
• Meet Optum performance and quality metrics while incorporating feedback from quality improvement reports and providing exceptional customer service
  Function as a vital aspect of a team consisting of other Physician Advisors, Nurses, Administrative Assistants, Clinical Relationship Managers, and Team Leaders with prompt responses to requests for assistance from any members of that team
• Performing all applicable administrative tasks, staying abreast of internal policies/procedures, regulatory changes and updates within the business segment, and completing and passing mandatory UHG and Optum Physician Advisor Service education modules
• Make engagement an area of focus and priority with commitment to the organization, colleagues and team members, as well as our clients
• Performing concurrent peer-to-peer discussions with payor medical directors on behalf of client hospitals
• Performing written and verbal appeals on behalf of client hospitals

You'llbe 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 asprovidedevelopment for other roles you may be interested in.

Required Qualifications:

• Licensed Physician (MD or DO) with a current, active, unrestricted Medical License in the U.S.
• Current Board Certification
• 3+ years of experience in a hospital-based practice setting
• Demonstrated computer proficiency (i.e., navigating multiple platforms simultaneously, proficient typing skills, MS Office Suite, etc.)
• Demonstrated ability to have meaningful and informed conversations with Case Managers and Attending Physicians
• Must be willing/able to adhere to the schedule expectations of the role and flexible to work evenings/weekends/holidays as business needs dictate and require
• Must be willing/able to work at least 3 holidays per calendar year

Preferred Qualifications:

• Active, unrestricted MD or DO License in CA

Soft Skills:

• Solid organization and communication skills
• Problem solving
• Team player mentality
• Solid clinical knowledge base
• Superior documentation skills
• Work Independently
• Self-motivated
• Dedicated remote workspace free from distractions following the company required telecommute compliance rules and regulations
• Work the designated schedule required per business needs

*All employees working remotely will berequiredto 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 For face-to-face roles use established pay transparency range $160,000 - $300,000 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,locationand 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 marginalizedgroupsand those with lower incomes. We are committed to mitigating our impact on the environment and enabling and deliveringequitablecare 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 adrug -free workplace. Candidatesare required topass a drug test before beginning employment.