GuideWell Source

Medical Director – Payment Integrity Officer

GuideWell Source

full-time

Posted on:

Location Type: Remote

Location: Florida • United States

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Salary

💰 $224,000 - $364,000 per year

Job Level

Lead

About the role

  • Overall case guidance and consulting to ensure that fraud, waste, and abuse efforts are performed with the highest and most current clinical standards
  • Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on services provided to members
  • Perform reviews and participate in peer-to-peer discussions of inpatient DRG Clinical Validation audits and appeals
  • Serves as a resource for information and consultation on the issues related to utilization management and clinical services
  • Approval and direction of consultant reviews. Participation in and support of overpayment recoveries
  • Support as needed to internal and external agencies in conjunction with these reviews such as but not limited to the Special Investigations Unit
  • Review of services suspected of being performed for purposes not medically necessary. Appropriate documentation of decisions and follow-up
  • Comply with all state, federal, and regulatory requirements
  • Other duties as necessary to ensure progression and completion of reviews
  • Participate on projects and committees as necessary

Requirements

  • MD or DO with an unrestricted FL medical license
  • 3+ years of experience in active clinical practice (primary care specialty desirable)
  • Excellent written and verbal communication skills with the ability to interact with all levels of the organization, external customers and providers
  • Ability to analyze data, measure outcomes, and develop action plans
  • Ability to intervene in crisis situations and multi-task
  • Conversant with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement.
  • Experience in utilization management, case review, and/or quality improvement activities in a managed care setting.
Benefits
  • Medical, dental, vision, life and global travel health insurance;
  • Income protection benefits: life insurance, short- and long-term disability programs;
  • Leave programs to support personal circumstances;
  • Retirement Savings Plan including employer match;
  • Paid time off, volunteer time off, 10 holidays and 2 well-being days;
  • Additional voluntary benefits available;
  • A comprehensive wellness program
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
CPT codingmedical claims reviewhospital billingreimbursementutilization managementcase reviewquality improvementdata analysisclinical guidelinesclinical validation audits
Soft Skills
written communicationverbal communicationinterpersonal skillscrisis interventionmulti-taskingdecision-makingconsultationproblem-solvingorganizational skillscollaboration
Certifications
MDDOunrestricted FL medical license