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Medical Director – Payment Integrity Officer
Location
Florida
Posted
83 days ago
Salary
$224K - $364K / year
Seniority
Lead
Job Description
Medical Director – Payment Integrity Officer
GuideWell Source
• Overall case guidance and consulting to ensure that fraud, waste, and abuse efforts are performed with the highest and most current clinical standards • Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on services provided to members • Perform reviews and participate in peer-to-peer discussions of inpatient DRG Clinical Validation audits and appeals • Serves as a resource for information and consultation on the issues related to utilization management and clinical services • Approval and direction of consultant reviews. Participation in and support of overpayment recoveries • Support as needed to internal and external agencies in conjunction with these reviews such as but not limited to the Special Investigations Unit • Review of services suspected of being performed for purposes not medically necessary. Appropriate documentation of decisions and follow-up • Comply with all state, federal, and regulatory requirements • Other duties as necessary to ensure progression and completion of reviews • Participate on projects and committees as necessary
Job Requirements
- MD or DO with an unrestricted FL medical license
- 3+ years of experience in active clinical practice (primary care specialty desirable)
- Excellent written and verbal communication skills with the ability to interact with all levels of the organization, external customers and providers
- Ability to analyze data, measure outcomes, and develop action plans
- Ability to intervene in crisis situations and multi-task
- Conversant with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement.
- Experience in utilization management, case review, and/or quality improvement activities in a managed care setting.
Benefits
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan including employer match;
- Paid time off, volunteer time off, 10 holidays and 2 well-being days;
- Additional voluntary benefits available;
- A comprehensive wellness program
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