Medical Director, Payment Integrity

  • UnitedHealth Group
  • Remote
  • Oct 05, 2021
Physician Any Specialty

Job Description

Transforming health care and millions of lives starts with the values you embrace and the passion you bring. Find out more and join us. It's an opportunity to do your life’s best work.(sm)

The Medical Director, Payment Integrity is responsible for providing expertise and general support to teams in reviewing, researching, investigating, negotiating and resolving all types of aberrant claims and utilization issues. They will communicate with appropriate parties, including but not limited to providers, vendors, and health plans regarding appeals, grievances and provider reconsideration requests. This individual will assist analyze and identify trends to address root causes and eliminate rework that is costly in terms of both dollars and working relationships. This role may research and resolve claims-related written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians/providers. 

The Medical Director will work to assist in the development and maintenance of relevant algorithms and methodologies to sustain a claims anomaly surveillance system; identify trends, outliers of concern, and improvement opportunities. They will be responsible for investigating and resolving all types of claim aberrancies as well as recovery and resolution for health plans, commercial customers, and government entities. This role will also review claims and medical documentation for medical necessity for claims CPT code usage, and for edits set for reviews by Claims and Payment Integrity team.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

  • Develop and grow strong partnerships with regional medical directors and local physician champions to execute on enterprise strategy and objectives
  • Assist Senior Medical Director to identify from claims data best and worst practices and resources by market, and share in actionable form the opportunities that Regional and Market Medical and Business Leadership and Network Contracting  might productively address
  • Work with Regional Leadership to develop and implement best practices and consistent process/tools across WellMed
  • Partners with leadership team to coordinate provider mentoring/education regarding    referral management, wise utilization, and fraud and waste reduction program components
  • Forms internal and external strategic relationships which will support program innovation, growth, expansion and the development of new programs
  • Directs others to resolve business problems that affect multiple functions or disciplines
  • Develops, translates and executes strategies or functional/operational objectives for a region, line of business, or major portion of a business segment functional area
  • Directs others to resolve highly complex or unusual business problems that affect major functions or disciplines
  • Develops, translates and executes strategies or functional and operational objectives at the business unit, multiple markets/sites and segment level

Personal and Physician Development

  • Strives to personally expand working knowledge of all aspects of the Payment Integrity leadership
  • An active participant in physician meetings
  • Assists in the growth and development of subordinates by sharing special knowledge with others and promotes continued education classes
  • Attends continuing education classes to keep abreast of fraud trends, medical advancements and innovative practice guidelines

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:

  • Active, unrestricted MD/DO license 
  • Board Certified in a Medical Sub-Specialty
  • 8+ years of experience in clinical documentation 
  • 5+ years of clinical practice experience
  • 3+ years of experience with Claims Oversight, Special Investigations, or anti-fraud and waste programs, CMS Program Integrity functions, or with Utilization oversight using claims data
  • 3+ years of experience with CMS Appeals and Payment Integrity Manual (PIM) regulations and process
  • 3+ years of experience working in risk bearing provider groups or health plan with population/medical management experience 
  • 2+ years of experience with CMS Medicare Administrative Contractor (MAC) as medical director with experience with CMS Program Integrity and work with NCD, LCD and Articles, along with NCCI edits and Appeals processes
  • Operations experience in large, matrix healthcare environment 
  • Working knowledge of CMS claims processing and payment requirements & regulations 
  • Knowledge of federal and state laws and NCQA regulations relating to managed care and medical management
  • Proficiency with Microsoft Office applications 

Preferred Qualifications:

  • 3+ years of experience with CMS Medicare Administrative Contractor (MAC) as medical director with experience with CMS Program Integrity and work with NCD, LCD and Articles, along with NCCI edits and Appeals processes

UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.


Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Colorado Residents Only: The salary range for Colorado residents is $254,600 to $295,200. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.      

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.