Medical Director, Clinical Chart Validation Team

Job Description:

• 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.
• 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.
• 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.
• 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.

Requirements:

• Must be a licensed physician with 5 + years’ clinical experience (preferrably in an inpatient setting, ER physician or hospitalist).
• Experience in private sector/ Health plan operations as a Medical Director, with focus on chart 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.).

Benefits:

• medical, dental, vision, disability, and life insurance coverage
• 401(k) savings plans
• paid family leave
• 9 paid holidays per year
• 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti

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