Medical Director (Medical Policy & Operations)
Core
Provide clinical expertise to promote high-quality medical care with a focus on clinical and payment policy, including transactional reviews for appeals, claim reviews, and predetermination of covered benefits.
Role type
Senior IC Medical Director (Medical Policy & Operations)
Builds
Clinical and payment policies for Commercial and Medicare environments
Domain
Health Insurance / Medical Policy
Required skills
Clinical expertise, Medical coding (HCPCS/CPT), Reimbursement expertise, Data analysis, Team leadership, Policy development
Preferred skills
Health plan/payor experience, Clinical policy knowledge, Health care systems knowledge
Responsibilities
Review clinical claims and appeals, Apply clinical coding and reimbursement expertise, Use data analysis to identify quality improvement opportunities, Lead diverse teams of health delivery professionals, Collaborate with functional areas
Seniority
Senior, hands-on IC