Medical Director

About the role

The Medical Director serves as a clinical subject matter expert and physician leader for an audit organization supporting governmental and commercial payer programs. This role provides medical oversight for audit strategy, clinical review methodologies, coding and documentation interpretation, claims validation, medical necessity determinations, and appeal support.

Responsibilities

• Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
• Review and interpret medical records, claims data, coding patterns, clinical documentation, and payer policies to support accurate audit determinations.
• Evaluate medical necessity, level of care, site of service, coding accuracy, documentation sufficiency, and alignment with applicable clinical standards and payer requirements.
• Support audit methodologies, clinical validation frameworks, sampling approaches, and quality assurance processes to ensure consistency, defensibility, and regulatory alignment.
• Apply knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to audit findings, provider education, and client deliverables.
• Partner with audit operations, coding, clinical review, data analytics, compliance, legal, and client-facing teams to resolve complex clinical and payment integrity issues.
• Provide physician-level review and support for disputes, rebuttals, grievances, appeals, and provider-facing clinical explanations.
• Develop and maintain clinical audit guidelines, review protocols, policy interpretation tools, and reviewer training materials.
• Monitor regulatory updates, payer policy changes, coding guidance, clinical practice trends, and audit risk areas that may affect governmental or commercial payer work.
• Support client engagements by explaining clinical rationale, audit findings, documentation expectations, and defensible review standards.
• Promote clinical accuracy, reviewer consistency, ethical audit practices, and continuous improvement across medical review operations.

Qualifications

• Strong understanding of governmental and commercial payer operations, including Medicare, Medicaid, Medicare Advantage, managed care, and employer-sponsored health plan environments.
• Demonstrated ability to interpret payer policies, medical necessity criteria, clinical guidelines, coding standards, and documentation requirements.
• Knowledge of claims adjudication, payment integrity, utilization management, risk adjustment, fraud/waste/abuse concepts, and audit operations.
• Ability to synthesize complex clinical, coding, and claims information into clear, defensible medical opinions and audit rationales.
• Strong written and verbal communication skills, including the ability to support client discussions, appeals, provider education, and internal reviewer guidance.
• Experience collaborating with coding professionals, nurse reviewers, data analysts, compliance leaders, legal teams, and payer stakeholders.
• Comfortable working in a structured audit environment with expectations for consistency, accuracy, timeliness, and regulatory defensibility.
• Commitment to ethical review practices, clinical integrity, confidentiality, and objective application of evidence-based standards.