Research Medical Director; Medicaid Medical Policy

Research Medical Director (Medicaid Medical Policy) Job Location s US-Remote   Category Clinical Position Type Full-Time Overview The Research Medical Director is a key member of the Clinical and Policy research development area  Research Medical Director is responsible for providing leadership guidance to the clinical teams and ensuring the Rules and policies are accurately interpreted and developed. This role 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 Payment Policy Management polices and rules. This is a full-time role and can work remotely in the US.

• 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.
• Perform QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to the 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.
• Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes.
• Maintains current knowledgebase of industry and content, best practices, applications, procedures and policies.
• Complete all responsibilities as outlined in the annual performance review and/or goal setting.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.

• A United States MD or DO degree is required. Additionally, an MBA degree is preferred.
• 10+ years of Research experience.
• Experience working with a Medicaid payer preferred.
• Knowledge of healthcare payers, policy payment and correct coding knowledge (preferred).
• Possess in depth knowledge of claims, claims adjudication, medical policy rules and edits.
• Strong organizational and project management experience preferred.
• Proven success as a manager in a scalable organization that has significant scope, complexity and breadth.
• Strong personal leadership - in terms of the role of a leader, the impact on the company and creating.
• Momentum for culture and accelerating the strategy.
• Relationship development skills to forge positive and lasting relationships with key business partners and clients.
• Ability to achieve sustainable results through others, including…

Equal Opportunity mployer/Protected Veterans/Individuals with Disabilities