Specialized Recruiting. Temporary Staffing. Managed Services. 800 876 2314

Medical Director

Employment Type Permanent
Field of Work Clinical/Medical


Position Summary

The Medical Director provides leadership, organization, and direction for claims review programs and may assist in the Utilization management programs and services.  Responsible for the overall quality, effectiveness and coordination of Company medical services.  Directs aspects of the medical claims reviews and coordinates these with Quality Improvement programs for the company.  The Medical Director will participate in all aspects of claim review services including provider telephonic discussions and provider appeals. The Medical Director may also be asked to assist in direction and oversight in the development and implementation of Policies and procedures and clinical criteria for all medical programs and services.  S/he will serve as a liaison between Company, physicians, and other medical service providers in selected situations primarily related to medical claim reviews.      


Primary Responsibilities

  • Reviews surgical and other professional claims for correct coding using clinical record  
  • Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable
  • Discusses cases and clinical coding situations with treating providers telephonically during scheduled hours
  • May assist in aspects of the utilization management and quality improvement programs
  • Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews
  • Composes, if needed, patient situation specific, clinical summaries and rationales for medical necessity decisions
  • Is available for occasional, periodic weekend and holiday as needed telephonic and remote computer expedited clinical decisions
  • Supports compliance with regulatory agency standards and requirements (e.g., CMS, NCQA, URAC, state / federal and third party payers)
  • Ability to travel to scheduled company meetings and activities in US
  • Ability to assist in marketing presentations to clients and ongoing relationship management activities with existing clients if requested to do so
  • Good understanding of professional performance measurement and related possible discussions/interventions with selected providers / groups / organizations.

Required Qualifications

  • Requires Board Certification in Surgery
  • Current and active Unrestricted, Medical license
  • Active Board certification in ABMS - recognized specialty applicable to this specialty area. ABMS or other nationally-recognized further specialized certifications are a plus
  • 5+ years clinical experience in relevant pain management clinical specialty post residency
  • Prior experience with professional claim coding / claim coding reviews is essential
  • Knowledge of all important claim coding resources and techniques
  • Excellent verbal and written communication skills
  • Diplomacy and tact in dealing with sensitive issues
  • Must possess leadership skills in working with other physicians, knowledge of the overall medical community and the local / regional managed care environments
  • Experience with integration of clinical and financial data, development of utilization and performance reporting tools, and communication of performance data to physicians and other health care providers
  • Proficient computer skills and ability to learn to use company clinical and claims software
  • Excellent interpersonal skills and the ability to work over the telephone with other colleagues including physicians, nurses, PTs, OTs and other similar personnel
  • MS Office (MS Word, Excel and Power Point)
  • Experience in managed care preferred