This Medical Director role focuses on clinical review and coding support for federal healthcare contracts, with work centered on Medicare and Medicaid payment, coverage, and documentation issues. The physician helps develop and edit fraud-prevention edits, answers complex medical record questions, and provides guidance to coders and contract staff. The role is highly collaborative and blends medical expertise with health care claims, compliance, and research support.
Key Responsibilities
- Participate in the production of PTP, Medically Unlikely Edits, and add-on code file edits.
- Provide clinical input in work group and contractor meetings.
- Serve as a clinical subject matter expert for complex medical record issues.
- Conduct research to support contract work, educational materials, and clinical guidance.
- Prepare research documents and support educational content for contract staff.
- Provide clinical and coding training to contract staff as needed.
- Interpret clinical documentation and help resolve disagreements about clinical guidelines.
- Support Medicare and Medicaid coding, coverage, and payment policy work.
Required
- Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree.
- Active, valid, unrestricted medical license in at least one U.S. state.
- Board certified for at least 3 years in an ABMS-recognized specialty.
- At least 3 years of experience practicing medicine as a board-certified physician.
- Experience in health insurance, utilization review, or health care claims processing with compliance responsibilities.
- Experience interpreting HCPCS/CPT codes and coding conventions.
Preferred
- Coding experience or certification.
Benefits & Perks
- Annual salary range of $240,000 to $280,000.
- Additional employee benefits package offered by the employer.
- Opportunity to work on federal contracts and public health-related programs.
- Consideration for candidates living in a HUBZone.