This role provides physician-level review and consulting support for payment integrity, medical necessity, reimbursement, and complex provider payment issues in managed care settings. The work centers on claims review, clinical validation, appeals, and dispute resolution for Medicare, Medicaid, Medicare Advantage, Special Needs Plans, and other risk-adjusted populations. It also includes advising client leadership on strategy, operations, and compliance while partnering with cross-functional teams to improve payment accuracy and outcomes.
Key Responsibilities
- Conduct clinical reviews and medical determinations related to payment, reimbursement, and utilization decisions.
- Provide physician-level expertise on claims review, clinical validation, medical necessity, and provider payment matters.
- Support resolution of complex clinical disputes, appeals, and reimbursement escalations.
- Assess and optimize payment integrity programs to improve performance and long-term value.
- Collaborate with internal teams and client stakeholders to identify payment accuracy opportunities.
- Translate clinical, operational, and financial findings into actionable recommendations for leadership.
- Present findings, recommendations, and strategic plans to client executives.
- Develop or update policies, procedures, workflows, and KPIs to support program goals.
Required
- MD or DO degree.
- Active medical license.
- Current board certification.
- Experience in managed care, payment integrity, utilization management, clinical auditing, reimbursement, or related healthcare operations.
- Strong knowledge of CPT, ICD-10, HCPCS, clinical documentation, and reimbursement methodologies.
- Experience managing provider disputes, appeals, or reimbursement escalations.
Preferred
- Experience with claims processing, provider contracts, data mining, or coordination of benefits.
- Experience with fraud, waste, and abuse work related to provider payment.
- Experience leading process improvement initiatives.
- Knowledge of commercial, Medicare, Medicare Advantage, or Medicaid lines of business.
- Familiarity with regulatory frameworks such as CMS, NCQA, URAC, HIPAA, or state insurance requirements.
- Proficiency with Excel, Word, PowerPoint, and Visio.
Benefits & Perks
- Hourly pay range of $100 to $150.
- Monday through Friday schedule, 8am to 5pm, with flexibility to adjust to client schedules as needed.
- Remote-style consulting work with travel only as needed by the client.
- Opportunity to support multiple managed care programs and high-level client engagements.
- No direct reports.