THIS POSITION CAN BE LOCATED REMOTELY ACROSS THE U.S.
The medical director role is responsible for providing clinical oversight and support of the Risk Adjustment and Quality as well as the Health Management areas of the organization.
- Delivers general education to providers relative to Medicare's risk adjustment model
- Provides education on documentation and coding to support the organization's risk adjustment programs
- Provides education to improve providers' performance in meeting quality measures as they pertain to Medicare's Stars rating
- Holds targeted education sessions based on observed documentation trends and market-specific needs
- Develops and continuously updates educational materials, digital and print, including tip sheets, slide decks and webinars
- Performs secondary reviews on services requiring prior authorization that don't meet medical necessity criteria and those requested by out of network providers
- Conducts peer-to-peer discussions with providers requesting to add clinical context to reverse a denial decision
- Renders decisions to uphold or overturn denials once all clinical information is gathered and reviewed
- Performs and documents decisions and discussions in accordance with applicable regulatory standards.
Clinical Reviews for Appeals and Grievances
- Reviews member requests for organizational determinations and renders decisions on medical necessity
- Performs clinical reviews and renders decisions on level 1 and level 2 provider appeals
- Reviews unfavorable decisions made by the IRE and assists with building a case to reverse these decisions
CDI Alert Review
- Performs review of CDI alerts returned by providers in the PEC program against documentation in the medical record when needed
- Creates queries requesting amended or additional documentation when needed
- Captures and enters risk-adjusting diagnosis codes in the MRR platform
- Identifies and tracks trends in provider documentation and coding and works with PECs to tailor and target provider education based on the specific needs in the market
General Clinical Support
- Brings the provider's perspective into the development of products, programs and materials across the organization
- Supports the organization and its clients through various audits that require clinical input
- Assists coders and PECs expand their clinical knowledge to improve their understanding of clinical documentation and facilitate their communication with providers in the field
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.