Medical Director – Physician Reviewer
MedReview Inc.
Clinical Compliance Medical Director
Elevance Health
full-time
Posted on:
Location: Virginia • 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- The Clinical Compliance Medical Director is responsible for providing clinical guidance related to the company’s coding guidelines, provider coding audits, and participates in developing an investigation team that focuses on potential fraud, waste and abuse in the provider population.\n
- Reviews provider medical record documentation to determine if there is potential fraud, waste, or abuse that warrants further investigations.\n
- Conducts provider interviews related to these investigations.\n
- Investigative material which includes provider medical record documentation.\n
- Provides clinical guidance regarding coding guidelines and develops provider educational material.\n
- Develops a more clinically focused provider audit process to obtain more meaningful results.\n
- Develops clinical review for investigations team including developing guidelines on how to implement the clinical analysis portion of the investigations and developing clinically relevant questions for provider interviews.\n
- Develops provider educational materials that are clinically focused and provides peer-to-peer compliance training and education to other providers internally and externally.\n
- Provides input to provider reporting from the provider perspective
Requirements
- MD or DO and Board certification approved by one of the following certifying boards is required: American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)\n
- Requires active unrestricted medical license to practice medicine or a health profession\n
- Clinical training and practice as a primary care physician required\n
- Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background
