Provide clinical expertise for medical policy, appeals, claim review, and predetermination of covered benefits across commercial and Medicare lines of business. This remote role blends utilization/policy review with clinical and payment policy support, using coding, reimbursement, and health plan knowledge to help guide consistent decisions and improve quality and efficiency. The position also serves as a subject matter expert and collaborates with cross-functional teams on data-driven opportunities and business objectives.
Key Responsibilities
- Conduct transactional reviews to support the appeal process, clinical claim review, and predetermination of covered benefits.
- Apply clinical coding and reimbursement expertise to align service and payment requests with company policy.
- Provide subject matter expertise in clinical policy and payment policy to support internal clinical and business direction.
- Participate on work groups to identify opportunities to improve the quality and efficiency of health care services.
- Use data analysis to identify quality improvement opportunities and support effective care delivery.
- Coordinate with functional areas and diverse teams of health delivery professionals to manage business objectives.
- Serve as an internal consultant and contributor on medical policy, coding, and reimbursement issues.
Required
- MD or DO degree.
- Active, unrestricted state medical license.
- Board certification in an ABMS-recognized specialty.
- At least 5 years of experience in health care delivery, such as clinical practice or the health care industry.
- At least 1 year of experience working for a health insurance company.
- Post-graduate direct patient care experience.
Preferred
- Health plan or payer experience.
- Knowledge of Aetna clinical and coding policy.
- Experience with appeals, claim review, reimbursement issues, and coding.
- Foundational knowledge of HCPCS/CPT, clinical policy, reimbursement, and health care systems.
- Strong written and verbal communication skills.
Benefits & Perks
- Remote work from anywhere in the United States.
- Full-time position.
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and additional family support resources.
- Eligibility for a bonus, commission, or short-term incentive program.
- Equity award program eligibility.