UnitedHealth Group
Location
Fort Wayne, IN | United States
Job description
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
This position is for qualified physicians seeking to enter the new and growing non-clinical practice specialty of Physician Advisor within a facility setting. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and its documentation. The Physician Advisor will be responsible for establishing, maintaining, and strengthening the relationship with Optum client hospitals to appropriately optimize the use of Optum services.
Training will be provided by Optum. The Physician Advisor will join a team of Optum physician advisors across the country.
Although the Physician Advisor (PA) is employed by Optum, the intention is that the PA will become a key member of the client hospital’s team charged with meeting the organization’s goals and objectives for ensuring the effective, efficient utilization of health care services. To this end, the PA will develop expertise on matters regarding medical necessity, documentation best practices and concurrent denial payor peer to peer interactions. Physician Advisor will be required to work onsite at the facility M-F during standard facility business hours.
The Physician Advisor will work closely with medical staff, including house staff and actively engage with hospital leadership and utilization management teams related to both medical necessity status reviews and concurrent denial reviews.
Primary Responsibilities:
Conduct second level medical necessity/compliance status reviews for all payor types
Requirement to gain and sustain a working knowledge of the technical systems to perform case reviews
Meet with case management, utilization management, social work, and other healthcare team members to discuss selected cases and make recommendations regarding patient status through case reviews
Interacting with medical staff to discuss medical necessity and concurrent denial cases
Act as a consultant for the medical staff regarding their decisions for the appropriate medical necessity status of hospitalized patients and supporting documentation
Participate in the claims denial process by conducting peer to peer discussions with commercial payor medical directors for cases that have been denied concurrently
Coordinate with Optum/OPAS Subject Matter Expert(s) for questions regarding federal, state and payor and regulatory requirements
Serve as a physician member of the Utilization Review Committee, which may require non-clinical medical staff privileges application
Provide focused case by case education on utilization management topics (e.g., documentation) to the medical and UM staff
Develop and maintain a working knowledge and understanding of OPAS proprietary guidance regarding clinical diagnoses and disease states. Initial and ongoing training will be provided by OPAS
Physician Advisor Will Not:
Practice medicine during the hours scheduled, which includes:
Decision-making in a patient’s plan of care or discharge
Write orders or prescriptions
Provide on-call coverage
Set hospital clinical or administrative policies
Supervise house staff or hospital employees
Participate in any type of peer review (e.g., Quality, M&M)
Participate in clinical research or clinical trials
Participate in the medical decision making of any hospital patient regarding appropriate treatment or course of medical care
Reproduce or recreate Optum’s proprietary guidance for distribution or use in any client educational modules
Execute any contracts on behalf of Optum
Post opinions related to medical necessity and patient status in any publicly disseminated publication/website without prior approval by appropriate Optum resources
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
• Current, unrestricted medical license in state of residence
• 3+ years of experience in a hospital-based practice setting
• Demonstrated ability to build rapport with medical staff and hospital leadership
• Proven solid computer skills and working knowledge of EMRs
• Proven receptive to feedback and coaching
• Proven solid communication and listening skills
•Demonstrated ability to collaborate and partner with multiple constituents (administrative, clinical, leadership, etc.)
• Demonstrated organizational agility, assumes positive intent, discovers the power pathways and circuits,
navigates the organizational maze to get things done
**** All Physician Advisors have a Shared, Minimum Holiday coverage requirement which is covered** remotely.
Preferred Qualifications:
• Board Certified / Eligible
• Prior Physician Advisor and or Utilization Review experience
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