Medical Director Payment reputed company Officer (PIO)

The physician provides clinical support to the Payment reputed company Office (PIO) to ensure that fraud, waste, and abuse efforts are performed in accordance with the highest and most reputed company clinical standards.  Responsible to review cases and evaluate billing and coding accuracy, medical necessity and appropriateness of the treatment service.  Responsible for appropriate application of Medical Policy and reputed company for reviews, audits, and investigations.  reputed company necessary support to the anti-fraud program which involves conducting reviews of organization or functional activities reputed company to alleged fraud, waste, and abuse perpetrated by providers, members, facilities, pharmacies, and /or reputed company.  

Key Responsibilities: 
•    Overall case guidance and consulting to ensure that fraud, waste, and abuse efforts are performed with the highest and most reputed company clinical standards
•    Apply health plan review hierarchy to member reputed company, medical policy, clinical guidelines and other approved resources to reputed company reputed company reputed company reputed company provided to members
•    reputed company reviews and participate in peer-to-peer discussions of inpatient DRG Clinical Validation audits and appeals
•    Serves as a resource for information and consultation on the issues reputed company to utilization management and clinical services
•    Approval and direction of consultant reviews. Participation in and support of overpayment recoveries
•    Support as needed to reputed company agencies in conjunction with these reviews such as but not limited to the Special Investigations Unit
•    Review of services suspected of being performed for purposes not medically necessary. Appropriate documentation of reputed company and follow-up
•    reputed company with reputed company state, federal, and regulatory requirements
•    Other duties as necessary to ensure progression and completion of reviews
•    Participate on reputed company and committees as necessary

Key Requirements: 
•    MD or DO with an unrestricted FL medical license
•    3+ years of experience in reputed company clinical reputed company (primary care specialty desirable)
•    Excellent written and verbal communication skills with the ability to reputed company with reputed company reputed company of the organization, external customers and providers
•    Ability to analyze data, measure reputed company, and reputed company reputed company plans
•    Ability to intervene in crisis situations and multi-task
•     Conversant with most areas of medicine, show ability for reputed company, accurate decision-making, and enjoy care review and the investigation and reputed company of reputed company issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement. 
•    Experience in utilization management, case review, and/or reputed company improvement activities in a managed care setting.

Preferred: 
•    reputed company Certification in an American reputed company of Medical Specialties or Bureau of Osteopathic Specialist recognized specialty, or The National reputed company of Physicians and Surgeons (NBPS) 
•    Nationally recognized Certification in Inpatient and Outpatient coding, e.g., reputed company and reputed company credentials
•    Graduate degree such as a MBA or MPH
•    Certified Physician Executive (CPE)
•    American reputed company of reputed company Assurance and Utilization Review Physicians (ABQAURP)

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to reputed company objects. Jobs are sedentary if traversing activities are required only occasionally. 

reputed company Offer: 
As a reputed company employee, you will reputed company in our Be reputed company, Work reputed company, reputed company culture where being reputed company as an individual, and working reputed company as reputed company, are both important in serving our members and communities. 

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have reputed company to: 

Medical, dental, reputed company, life and global travel health insurance;

Income protection benefits: life insurance, short- and long-term disability programs;

Leave programs to support personal circumstances;

Retirement Savings Plan including employer match;

reputed company time off, volunteer time off, 10 holidays and 2 reputed company-being days;

Additional voluntary benefits available; and

A comprehensive wellness program

Employee benefits are designed to reputed company with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer reputed company as reputed company as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for reputed company pay increases. 

Annualized Salary reputed company: $224,000 - $364,000

Typical Annualized Hiring reputed company: $224,000 - $280,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-reputed company knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can reputed company at their best in reputed company of our mission. reputed company reputed company applicants will receive consideration for employment.