Medical Director

3 days ago

Remote, Oregon, United States CERIS Full time $200,000 - $300,000 per year

JOB SUMMARY:

This position will provide medical expertise as a consultant in the development and review of claims review policy. This individual will support CERIS's application of CMS, client and industry standing billing guidelines in circumstances included by not limited to: peer to peer reviews, arbitrations, administrative law hearings and/or mediations by illustrating the relationship between the guidelines CERIS applies to claims review with clinical practice. Drive CERIS's best practice policies toward consistent and innovative claim review.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

  • Assist with development and research of reimbursement and/or clinical policies that affect CERIS reviews including itemized bill review and DRG.
  • Proactively maintain an awareness of current laws, statutes, regulations, etc. that impact healthcare operations, and assist in strategizing the application of those guidelines to CERIS reviews.
  • Conduct peer to peer reviews on DRG claim reviews as needed
  • Verbally communicate interpretation of CMS, Federal, State and client policies to providers and clients as needed.
  • Analyze and review items disallowed by CERIS are consistent with CMS published guidelines on an annual basis.
  • Serve as a witness in legal proceedings such as arbitration, bench trials or mediation to support CERIS reviews.

KNOWLEDGE & SKILLS:

  • Knowledge of nationally recognized criteria (e.g., Milliman, Interqual etc.), medical necessity and benefit interpretation for both ambulatory and inpatient care.
  • Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format.
  • Understanding of general health plan and regulatory requirements for utilization management, denials and appeals.
  • Strong understanding of healthcare revenue cycle and claims reimbursement.
  • Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative.

EDUCATION/EXPERIENCE:

· Requires MD or DO from an accredited medical school

· Board Certification or Eligibility in a primary care specialty preferred

· A current and unrestricted medical license in at least one jurisdiction and willing to obtain additional license, if required.

· No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.

· Experience in acute clinical care areas of facilities in OR, ICU, CCU, ER, Telemetry, Medical/Surgical, OB or L&D, Geriatrics and/or Orthopedics.

· 5+ yrs clinical practice

· 2+ yrs experience as a health plan Medical Director preferred

· 2+ yrs HMO/Managed Care experience

Job Type: Contract

Work Location: Remote

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