The Medical Director (MD) is a key member of the audit, quality assurance and client team. The Medical Director is responsible for representing the team on all audit and appeals decisions. The Medical Director is also responsible for analyzing, interpreting, and developing additional policies that will allow us to enhance our medical policy library. The Medical Director will guide both internal and external processes as related to CCV inpatient audit, documentation, and communication of results.

• Inpatient Audits (Prepayment & Retrospective)
• Performs billing and coding audits to ensure charges are supported by the appropriate clinical documentation, review medical records, and document findings in Cotiviti and client systems as necessary.
• Conducts reviews of medical records, charges and associated documentation, researching and applying knowledge related to billing and coding guidelines searching for billing, coding and unsupported (or clinical) documentation in provider billing.  Analyzes medical record documentation to determine the accuracy and completeness of clinical and coding information in support of correct claim coding and billing guidelines.
• Manages the workflow and deadlines to ensure accuracy and timeliness of audit results are consistent with client, federal, and state rules, regulations, and guidelines as applicable.
• Upholds HIPAA privacy and security guidelines.
• Appeals administration and oversight
• Conduct audit of appeals on claims originally recommended for changes by another CCV Auditor to uphold or overturn the original audit decision.
• Review new support evidence and/or documentation and gather other information as needed.
• Participate in client and provider meetings to review and discuss audit case findings and results.
• Research and Development
• Assist the Clinical Audit Manager and Research Department to develop medical policy edits.
• Develop scorecards for existing rules-based logic to analyze trends in current rules-based audit selection criteria and recommend ongoing optimization.
• Quality Assurance Program support
• Participate in the design and implementation of the QA program and provide support for ongoing quality assurance audits for interrater reliability and coding accuracy.
• Support new sales activity and existing client growth by identifying value creation opportunities for our clients.
• Other duties as assigned.

 Other Related Responsibilities

• Delivers personal assignments reliably and on-time through organized personal work processes.
• Produces quality work that considers the client’s (internal and external) needs and qualitative self-review process.
• Exhibits behaviors consistent with Cotiviti Values. 

RELEVANT EXPERIENCE & EDUCATIONAL REQUIREMENTS:

• Must be an MD with 5 + years’ experience in an inpatient setting, ER physician or hospitalist preferred.
• Experience in private sector/ Health plan operations as a Medical Director, with focus on utilization review, medical coding (CPT, ICD-9) or appeals and grievances.
• Experience in DRG auditing preferred.
• Coding certification (CCS, CPC or CIC) preferred or willingness to obtain / maintain.
• 5+ years’ experience using InterQual or MCG/Milliman criteria.
• 5+ years’ experience using decision support group software (3M, etc.).

 SKILLS & COMPETENCIES

• Excellent verbal and written communication skills.
• Strong analytical and problem solving skills.
• Intermediate Microsoft Office skills (Word, Excel, and PowerPoint).
• Strong organizational skills and adaptive capacity for rapidly changing priorities and workloads.

Mental Requirements:

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.

Physical Requirements and Working Conditions:

• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access/connectivity and office setup and maintenance.
• No adverse environmental conditions are expected.

Base compensation ranges from $190,000 to $260,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

Date of posting: 1/10/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 3/10/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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