Medical Director (Research)
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POST DATE 8/13/2016
END DATE 11/1/2016
Cotiviti USA, LLC
The Research Medical Director is a key member of the clinical operations and research team responsible for the research, quality assurance, and opportunity analysis associated with new medical policies. This position is a contributor to the client team, and represents the Research team on all Medical Policy decisions. In addition, this position will be responsible for review and analysis of current medical policies and assisting in the research necessary to define additional logic and algorithms to expand the Cotiviti payment policy library. This position works in coordination with a global research team consisting of clinical and non-clinical professionals.
* Interpret and assess payment policy and medical coding information / guidelines against our policy library for maintenance of existing policy and development of new policy
* Conducts thorough research and analysis for medical policy items
* Performs multi-faceted analytics for data and report analysis
* Responsible for translating industry references into Cotiviti policy
* Reviews and identifies changes to medical policies in order to maintain an accurate and current medical policy library
* Identifies new opportunities as appropriate from both clinical reference and analytical sources
* Analyze research inquiries from a multitude of sources and apply solid clinical judgment to determine potential impact to medical policies
* Ability to determine if an update to existing policy logic or content is warranted based on changes to industry or Cotiviti reference data
* Perform QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to originator as needed.
* Educates client-facing MDs and Client Policy Managers (CPMs) on new changes and policy updates by actively participating in monthly meetings for client facing MDs and CPMs
* Manages interactions with our expert panel (consultant pool) on relevant clinical issues
* Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes.
* Maintains current knowledgebase of industry and Cotiviti content, best practices, applications, procedures and policies
* Degree in Medicine (MD or DO) active or in-active license
* Professional certification (CPC, CPC-H, CPC-P or CCS-P) or willingness to attend coding boot camp sponsored by the Company
Skills, Experience, and Other Requirements
* Minimum of 5 years of experience in a clinical setting
* Minimum of 3 years of experience in internet based research as it relates to codes (CPT, HCPCS, ICD, etc.)
* Experience in a health plan, Medicare or State Medicaid with focus on reimbursement and/or coding preferred (CPT, ICD-10, etc.). Equivalent experience would be knowledge through a payer services organization working with one or more of the organizations noted above.
* Experience developing medical payment policy edits or algorithms (preferred)
* Maintains high degree of flexibility in performing research and analysis
* Responsive to learning new tools and analytical techniques
* Considers rule interactions and interconnectedness of current systems
* Capable of relating current system and operational responsibilities into new system and process design
* Exhibits accuracy and thoroughness
* Possess in depth knowledge of claims, claims adjudication, medical policy rules and edits
* Strong organizational and project management experience preferred.
* High attention to detail
* Strong analytical, critical thinking and problem solving skills
* Works with a sense of urgency
* Prior health plan operations experience helpful
* Prior understanding of client policy or client implementation services helpful
* Proficient with Microsoft Office Suite (Word, Excel, Power Point); Intermediate Excel
* Professional with ability to properly handle confidential information
* Ability to work well independently and in a team environment.
* Ability to handle multiple tasks, prioritize and meet deadlines.
* Ability to work within a matrix organization
* Excellent written and verbal communication skills
* Communicates with ease up and down the chain of leadership
* We are an Equal Opportunity Employer.
* Please view Equal Employment Opportunity Posters provided by OFCCP here.
* Cotiviti is an Equal Opportunity Employer. The Company provides equal employment opportunities to all applicants for employment without regard to gender, sexual orientation or preference, gender identity or expression, race, color, religion, national origin, ethnicity, ancestry, age, marital status, pregnancy, childbirth or related medical conditions, mental or physical disability, veteran status or any other characteristic protected by federal, state or local law, ordinance or regulation..
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin. We are also an equal opportunity employer of individuals with disabilities and protected veterans. Please view Equal Employment Opportunity Posters provided by OFCCP here.