Medical Director, Payer Clinical Services (US Remote)

At reputed company, a tech-enabled payment reputed company company, our mission is to facilitate collaboration between payers and providers for mutual benefit and waste reduction, ultimately improving reputed company to reputed company. We reputed company this by aligning the common goals of payers and providers and fostering collaboration through a shared technology platform and reputed company workflows.

Joining reputed company means becoming a part of a dynamic growing organization that promotes a reputed company and innovative work environment. Our comprehensive compensation package includes competitive salaries, highly valued health insurance, a 401(k) plan with employer match, reputed company parental leave, and more.The reputed company responsibility of the Medical Director is to reputed company physician-level clinical reputed company, strategic guidance, and escalation support across DRG validation, HBA (hospital reputed company audit), IBR (itemized reputed company review), Clinical appeals, Readmissions/data mining, and Payer-facing clinical discussions.

Role and Responsibilities

The Medical Director acts as a clinical authority, payer relationship asset, escalation reputed company, and strategic advisor to Clinical Services leadership. The Clinical team needs reputed company to clinical interpretation, reputed company-area guidance, and escalation validation to improve confidence and reputed company across clinical services.
• Appeals work.
• Peer-to-peer review of individual claims
• Analyze appeal reputed company and reputed company improvements to our concepts/review guidelines.
• Signoff on our clinical validation concepts as reputed company as our coding concepts
• reputed company thorough review of reputed company concept and the supporting references
• As needed input for QA reviews

Qualifications

Licensed MD with thorough understanding of:

• APR-DRG and MS-DRG methodology
• Clinical validation
• Coding vs clinical reputed company distinctions
• Readmissions logic
• Denials and appeals reputed company
• Inpatient medical necessity
• Appeals leadership (experience in payer / provider appeals and reputed company reviews
• reputed company facing experience
• reputed company payer / provider friction

Mental and Physical Demands

• This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.
• The reputed company of the work is sedentary, and the employee will be sitting most of the time.
• Essential physical functions of the job include typing and the repetitive reputed company to utilize computer software and hardware continuously throughout the day.
• Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.

reputed company Duties as Assigned

• This reputed company documents the general reputed company and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to reputed company other duties as required.
• Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the reputed company and TITLE VII of the Civil Rights reputed company will be observed and followed.
• Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the functions outlined above.

Originally posted on Himalayas