Medical Director-Payment Integrity
Core
Medical Director determines authorization of inpatient and post-acute care services based on clinical guidelines and CMS policies.
Role type
Senior IC physician utilization management director
Builds
Medical determinations for Medicare/Medicaid/Commercial coverage
Domain
Healthcare / Managed Care / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical interpretation, regulatory compliance, clinical record review, dispute resolution, coding practices, quality management, utilization management, case management, discharge planning, home health, post-acute services
Preferred skills
Managed care industry knowledge, MCG/InterQual guidelines, Internal Medicine/Hospitalist/Geriatrics/Emergency Medicine specialization, MBA/MHA/MPH, population health analytics
Technologies
MCG, InterQual
Responsibilities
Review clinical records for inpatient/post-acute scenarios, communicate authorization decisions, conduct peer-to-peer discussions, manage appeals and grievances, oversee coding and documentation compliance
Seniority
Senior, hands-on IC