Pennsylvania Licensed Medical Director
Job Summary
To support the growth of a Clinical Payment Integrity function, the fully remote Pennsylvania Licensed Medical Director will provide clinical oversight for payment integrity programs, engage with providers, and ensure alignment with reimbursement policies and regulatory requirements.
Key Responsibilities
- Conduct clinical reviews and render medical determinations for payment reviews and audits
- Serve as a senior clinical liaison to provider organizations, addressing payment policies and reimbursement issues
- Collaborate with cross-functional teams to develop and govern payment integrity policies and strategies
Required Qualifications
- Active, unrestricted physician license and current board certification
- Minimum seven (7) years of clinical practice experience
- Experience in managed care, utilization management, or payment integrity
- Strong knowledge of CPT, ICD-10, HCPCS, and healthcare reimbursement methodologies
- Experience managing complex provider disputes and reimbursement-related escalations
Complete Job Description
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