Medical Director

About the role

The Medical Director serves as a clinical resource and consultant to hospitals by providing identification, facilitation, and resolution of denials. The Medical Director will be responsible for timely completion of assigned peer to peers and documentation of the outcomes. The Medical Director will also provide physician education regarding accurate determination and documentation of the admission status/level of care and presence of complications or comorbidities.

What you will do in this role

• Conducts peer to peers with health plan counterpart for denied inpatient cases
• Acts as a liaison with payers to facilitate approvals and prevent any denials
• Facilitates, mentors, and educates other physicians regarding payer requirements
• Performs data analysis related to utilization review (UR) metrics, works with hospital utilization management committees upon request to develop, implement, and monitor action plans related to denial reduction and authorization of level of care
• Offers input on managed care contracting issues, best demonstrated practices, process improvement and utilization management activities, barriers to achieving goals and objectives of initiatives, and denials prevention initiatives
• Demonstrates leadership, collaboration, and effective communication skills
• Participate in the concurrent and retrospective appeal peer-review process
• Provides oversight to the pre bill denial strategy within the payer process
• Schedules and manages meetings with payer medical directors for collaboration and process improvement
• Functions as a core team member of the denial management team
• Educates physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records

Qualifications

• Licensed (or eligible for licensure) Physician (MD/DO) in a state in the United States
• Board Certification Required (Internal Medicine and Family Medicine preferred)
• Preferred work experience as a physician advisor
• Minimum of 5 years of experience in clinical practice
• Knowledge of InterQual, Milliman or related evidenced based criteria sets
• Familiar with Joint Commission, State and Federal standards/requirements, and DRG vs Per diem reimbursement models
• Knowledgeable about third party payer source criteria of medical necessity
• Organized and able to meet deadlines consistently
• Computer experience required with skills including but not limited to Microsoft Windows, spreadsheets, and word processing

Benefits

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more
• Free counseling services and resources for emotional, physical and financial wellbeing
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock
• Family support through fertility and family building benefits with Progyny and adoption assistance
• Referral services for child, elder and pet care, home and auto repair, event planning and more
• Consumer discounts through Abenity and Consumer Discounts
• Retirement readiness, rollover assistance services and preferred banking partnerships
• Education assistance (tuition, student loan, certification support, dependent scholarships)
• Colleague recognition program
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income

This response is AI-generated, for reference only.