Medical Director (Clinical Chart Validation Team)

Cotiviti; United States; Remote; USD 190,000 - 260,000; Full time

Job summary

An established industry player is seeking a Medical Director to lead audit and quality assurance initiatives. This role is crucial for enhancing medical policy libraries and guiding both internal and external processes related to clinical chart validation. The ideal candidate will possess extensive experience in inpatient settings and medical coding, ensuring compliance with billing guidelines while managing audit workflows. Join a forward-thinking team that values innovation and quality in healthcare delivery, offering a competitive salary and comprehensive benefits to support your professional growth.

Benefits

Medical insurance

Dental insurance

Vision insurance

Disability insurance

Life insurance

401(k) savings plan

Paid family leave

Paid Time Off (PTO)

Paid holidays

Qualifications

• Must be an MD with 5+ years' experience in an inpatient setting.
• Experience in health plan operations as a Medical Director.
• Coding certification preferred or willingness to obtain.

Responsibilities

• Perform billing and coding audits to ensure documentation accuracy.
• Conduct reviews of medical records and associated documentation.
• Participate in client and provider meetings to discuss audit findings.

Skills

Verbal and written communication skills

Analytical skills

Problem solving skills

Microsoft Office skills (Word, Excel, PowerPoint)

Organizational skills

Education

MD with 5+ years' experience in an inpatient setting

Experience in private sector/Health plan operations

Coding certification (CCS, CPC or CIC)

Tools

InterQual

MCG/Milliman criteria

3M decision support group software

Job description

Medical Director (Clinical Chart Validation Team)

Job Locations

US-Remote

ID

2025-14095

Category

Clinical

Position Type

Full-Time

Overview

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.

Responsibilities

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.

Qualifications

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 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.).

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: 04/18/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 06/18/2025, 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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