Research Medical Director (Medicaid Medical Policy)

Responsibilities

• Interpret and assess payment policy and medical coding information / guidelines against our policy library for maintenance of existing policy and development of new policy.
• Conducts thorough research and analysis for medical policy items.
• Performs multi-faceted analytics for data and report analysis.
• Responsible for translating industry references into Cotiviti policy.
• Reviews and identifies changes to medical policies in order to maintain an accurate and current medical policy library.
• Identifies new opportunities as appropriate from both clinical reference and analytical sources.
• Analyze research inquiries from a multitude of sources and apply solid clinical judgment to determine potential impact to medical policies.
• Determine if an update to existing policy logic or content is warranted based on changes to industry.
• Perform QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy.
• In addition to QA, provides feedback to the originator as needed.
• Educates client-facing MDs and Client Policy Managers (CPMs) on new changes and policy updates by actively participating in monthly meetings for client facing MDs and CPMs.
• Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes.
• Maintains current knowledgebase of industry and content, best practices, applications, procedures and policies.

Qualifications

• A United States MD or DO degree is required.
• Additionally, an MBA degree is preferred.
• 10+ years of Research experience.
• Experience working with a Medicaid payer preferred.
• Possess in depth knowledge of claims, claims adjudication, medical policy rules and edits.
• Strong organizational and project management experience preferred.
• Proven success as a manager in a scalable organization that has significant scope, complexity and breadth.
• Strong personal leadership – in terms of the role of a leader, the impact on the company and creating momentum for culture and accelerating the strategy.
• Relationship development skills to forge positive and lasting relationships with key business partners and clients.
• Ability to achieve sustainable results through others, including the development and assignment of other MDs and administrative staff as leaders, mentors, trainers, etc.