Enterprise Medical Director, Post-Service Review & Medical Claims Review (MCR)
Core
Develop and implement corporate clinical care standards, quality improvement plans, and medical review policies for high-dollar claims and hospital-acquired conditions.
Role type
Enterprise Medical Director (Post-Service Review & Medical Claims Review)
Builds
Payment integrity programs, clinical audit methodologies, and provider engagement strategies for high-dollar claims and HACs.
Domain
Healthcare administration and medical claims review
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical degree (MD/DO), residency training, clinical practice experience, managed care medical review experience, regulatory compliance knowledge, data analysis, leadership, conflict resolution
Preferred skills
Business Administration degree, operational excellence knowledge, healthcare administration experience
Technologies
Microsoft Word
Responsibilities
Develop and revise quality improvement plans and corporate clinical standards; lead medical economics analytics and utilization management; support regulatory compliance (CMS, NCQA, URAC); conduct clinical reviews and prior authorization for high-dollar claims; evaluate cases for fraud, abuse, and quality concerns; provide provider education and training; oversee assigned managers and associates; lead MCR operating model and clinical audit methodologies.
Seniority
Senior, hands-on IC with leadership responsibilities
