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.

Primary Scope of Service:
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 Pennsylvania
• Demonstrated ability to build rapport with medical staff and hospital leadership
• Solid computer skills and working knowledge of EMRs
• Receptive to feedback and coaching
• 3+ years of experience in a hospital-based practice setting
• Solid communication and listening skills
• Ability to collaborate and partner with multiple constituents (administrative, clinical, leadership, etc.)
• 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
• Physician Advisor and or Utilization Review experience

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, location and 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 marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care 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 a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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