Medical Director, Clinical Integrity & Review
- Job Title
- Medical Director, Clinical Integrity & Review
- Job ID
- 27753255
- Work Remote
- Yes
- Location
- Remote
- Other Location
- Description
-
Medical Director, Clinical Integrity & Review
Remote U.S.
@Orchard LLC is supporting a not-for-profit corporation that partners with public and private sectors to create high-quality, safe, and efficient delivery of health care and human services programs. Our client has multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Our client is also a national leader in fighting fraud, waste, and abuse for large organizations across the country. In addition, our client operates a foundation providing grant opportunities to those with programs for under-served communities.
The Medical Director is responsible for assuring the clinical integrity of the organization, their products, and our services, with particular focus on contract(s) in multiple jurisdictions, including federal and state. Will evaluate medical necessity and provide quality assurance review to ensure adherence to regulations and guidelines. The Medical Director will also provide administrative and clinical support to assigned project teams.
Medical Director Essential Duties and Responsibilities will include:
Medical Review Oversight may include:- Physician peer review activities
- Criteria development and assessment
- Correspondence regarding review determination
- Recruitment, credentialing, and training of expert physician reviewers
- Managing the expert physician advisory network in specific geographic areas
- Serving on external committees
Professional Relations may include:- Interfacing with external organizations including physician specialty groups, hospital associations, medical societies, affiliates contractors, and state and federal agencies
- Discussing specific clinical issues with attending physicians
Health Care Quality Improvement/Assurance may include:- Leading and/or participates in quality improvement projects as needed
- Providing clinical input to specific projects as required by the organization or contractors
- Supporting project managers or teams with specific collaborative projects as needed
- Maintaining working knowledge of current quality improvement issues and tools
Required Skills and Experience:
Education and/or Experience:- Doctoral degree (MD) with at least 10 years clinical experience or at least 5 years in an administrative position in health care, with a focus of quality improvement or quality assurance.
- Advance degree in public health or health care administration preferred. May consider an equivalent combination of education and experience.
- Solid understanding of Medicare Part A and Part B claims and a great understanding of the Medicare system and billing.
- Depending on contract requirements may also require additional experience; experience with Medicare and/or Medicaid; and/or board certification.
- Medical Review experience preferred.
Other Skills and Abilities:- Uses knowledge and experience to interpret medical polices and guidelines. Complies with specific contract requirements.
- To perform this job successfully, an individual should have knowledge of Word Processing software.
- Must have basic understanding of the use of the computer.
Certificates, Licenses, Registrations:- Valid, current, active, and unrestricted clinical physician license and practice as a health professional in a state or territory of the United States. California license preferred.
Travel Requirements:- Travel requirements vary based on contract requirements may require periodic overnight and/or local travel. Must be willing to travel in accordance with company and contract needs.
If you match the requirements for this opportunity and believe you have the experience and talent to succeed in the role, we need to hear from you!
Established in 2010, @Orchard LLC, also known as, Talent Orchard has an exceptional reputation, providing staffing solutions to time-sensitive, talent scarcity issues to deliver better talent management ROI. Our specialty lies in the critical area of program talent acquisition and resource management, not in one narrow skillset, but across many areas of technical and functional delivery. To learn more about our other exciting opportunities, visit our Jobs Page at www.atOrchard.com.
