Payment Integrity Physician Reviewer

We need to output HTML fragment with sections: About the role? Actually we have Company Description, Position Responsibilities (Specific and General), Position Qualifications (Competencies), Experience, Physical Requirements, Time Zone, Other Information (Expected Hours, Travel, Direct Reports, Salary Range). We must not repeat job title as heading. Use

for section headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. But we only include sections when posting has real specific content. We need to map content to these headings appropriately. We have: - Company Description: could be "About the role"? Actually "About the role" maybe includes company description and role overview. We'll put company description under

About the role

with

. - Responsibilities: we have Specific and General responsibilities. Combine into a

• list. - Requirements: maybe "Position Qualifications" includes competencies, qualifications. Could be under

  Requirements

  or

  Qualifications

  . The instruction says use headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to decide which to use. We have qualifications (advanced managed care expertise, etc.) and experience (medical degree, etc.) and competencies (strategic leader, etc.) and skills (communication, office software). We could put qualifications under

  Qualifications

  , experience under

  Experience

  but Experience is not in list; maybe we fold into Qualifications or Requirements. The list includes Requirements and Qualifications separate. We could put core qualifications (like MD, license) under Requirements, and broader competencies under Qualifications. Or we could combine. We also have Physical Requirements, Time Zone, Other Information (Hours, Travel, Direct Reports, Salary Range). Pay and Schedule sections: we have Salary Range ($100-$150/hr) and Expected Hours (Mon-Fri 8am-5pm). So we can include Pay and Schedule sections. Benefits: not mentioned, so omit. Skills: we have communication skills, office software proficiency, etc. Could be under Skills. Thus sections: - About the role (company description) - Responsibilities (specific + general) - Requirements (maybe medical degree, license, board certification, experience in claims processing, etc.) - Qualifications (advanced managed care expertise, C-suite experience, strategic leader, etc.) - Skills (communication, office software, Visio preferred) - Pay (salary range) - Schedule (expected hours, ability to adjust, travel maybe? Travel could be under Schedule or separate but we only have Schedule heading; we could include travel note in Schedule section.) We must not include headings with filler. Ensure we preserve all substantive info. We need to remove boilerplate: EEO statement, cookie/navigation/legal etc. Remove duplicated lines. Let's extract content. Company Description paragraph: "Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity." Responsibilities: Specific: - Assess, develop, and optimize Payment Integrity programs to provide long-term, sustainable value. - Support the implementation and execution of customized strategic initiatives designed to meet and exceed program and operational goals. - Apply analytical and quantitative approaches to problem-solving and utilize statistical concepts to evaluate Payment Integrity opportunities and performance. - Provide physician-level clinical expertise related to claims review, clinical validation, medical necessity, reimbursement, and complex provider payment matters. - Support the review and resolution of complex clinical disputes, appeals, and reimbursement-related escalations. - Collaborate with cross-functional teams and other stakeholders to identify and address payment accuracy opportunities. - Translate clinical, operational, and financial findings into actionable recommendations for client leadership. General: - Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance - Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services - Deliver innovative, integrated solutions in support of client goals and engagements. - Lead engagements ensuring completion of all contracted services - Present findings, recommendations and plans to Client executives - Facilitate complicated problem-solving discussions to drive to timely, effective decision making - Advise and persuade key decision makers and influencers - Deliver concise, clear interpersonal communication to both internal and external audiences - Facilitate streamlined executive summaries, next step recommendations and communication to all levels of Clearlink and client/ partner organization(s) - Articulate performance across multiple projects with qualitative and quantitative results/ outcomes - Influence others to best course of action through advanced understanding of changing business landscapes - Develop strategies, goals and plans in response to changing business conditions - Leverage best practice methodologies and approaches across individual account strategies/ client plans. - Establish short term KPIs and long-term goals and track progress to ensure achievement - Develop or update policies, procedures and workflows as required to support business needs and requirements - Coach and mentor staff to reach established engagement goals, plan deliverables and KPIs - Adapt process, approach, plan and/ or activities in real time to mitigate risk and ensure critical path activities - Support account management relationships with key client decision makers Position Qualifications (Competencies) list: - Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance - Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes - New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/ or associated lines of business - New population strategy development including identification, program design and implementation - Operationalizing requirements for complex memberships, ensuring outcome delivery - Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity - Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures. - Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion - Advanced knowledge of project management principles, methods, and techniques - Ability to organize, prioritize, and manage multiple complex projects simultaneously - Excellent communication skills both written and oral - High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred Experience: - Medical Degree (MD or DO) required; Must be actively licensed and current board certification - Expertise in claims processing, provider contracts, data mining, and coordination of benefits, including fraud, waste, and abuse as they relate to provider payment. - Demonstrated experience leading small- and large-scale process improvement initiatives. - Experience in managed care, payment integrity, utilization management, clinical auditing, reimbursement, or related healthcare operations. - Experience conducting clinical reviews and medical determinations for payment, reimbursement, or utilization decisions. - Strong knowledge of CPT, ICD-10, HCPCS, clinical documentation, and reimbursement methodologies. - Knowledge of payment policies, medical necessity criteria, clinical guidelines, and regulatory requirements. - Experience managing complex provider disputes, appeals, and reimbursement escalations. - Strong communication and relationship management skills with providers, executives, and cross-functional teams. Physical Requirements: - Must be able to sit in a chair for extended periods of time - Must be able to speak so that you are able to accurately express ideas by means of the spoken word - Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices - Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse - Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types - Must be able to fluently communicate both verbally and in writing using the English language - Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously Time Zone: Eastern or Central Other Information: - Expected Hours of Work: Monday - Friday 8am – 5 pm; with ability to adjust to Client schedules as needed - Travel: May be required, as needed by Client - Direct Reports: None - Salary Range: $100.00 - $150.00/ hr EEO statement removed. Now produce HTML. We need to use

  for each section heading. Use

  • for any list of duties/requirements/benefits. Use

    for prose. We need to decide which content goes under which heading. Let's map: About the role: company description paragraph. Responsibilities: combine Specific and General responsibilities into a single list (maybe two sublists? but we can just list all items). Use

    • . Requirements: maybe the Experience section (medical degree, license, expertise, etc.) plus Physical Requirements? Physical requirements could be under Requirements as well. But we have separate heading for Requirements; we can include medical degree, license, experience, expertise, knowledge, etc. Physical requirements maybe also under Requirements but could be separate? Not in list. We'll include them under Requirements as they are requirements. Qualifications: the Competencies list (advanced managed care expertise, C-suite, etc.) Skills: communication skills, office software proficiency, Visio preferred (maybe also from Experience). But we already have communication skills in Qualifications; but we can still list under Skills. Pay: salary range. Schedule: expected hours, ability to adjust, travel, time zone? Travel maybe under Schedule. Time zone also. We must not create sections with filler. Ensure we have real content. Let's craft. HTML:

      About the role

      Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

      Responsibilities

      • Assess, develop, and optimize Payment Integrity programs to provide long-term, sustainable value.
      • Support the implementation and execution of customized strategic initiatives designed to meet and exceed program and operational goals.
      • Apply analytical and quantitative approaches to problem-solving and utilize statistical concepts to evaluate Payment Integrity opportunities and performance.
      • Provide physician-level clinical expertise related to claims review, clinical validation, medical necessity, reimbursement, and complex provider payment matters.
      • Support the review and resolution of complex clinical disputes, appeals, and reimbursement-related escalations.
      • Collaborate with cross-functional teams and other stakeholders to identify and address payment accuracy opportunities.
      • Translate clinical, operational, and financial findings into actionable recommendations for client leadership.
      • Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance.
      • Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services.
      • Deliver innovative, integrated solutions in support of client goals and engagements.
      • Lead engagements ensuring completion of all contracted services.
      • Present findings, recommendations and plans to Client executives.
      • Facilitate complicated problem-solving discussions to drive to timely, effective decision making.
      • Advise and persuade