Medical Director, Payer Clinical Services (US Remote)
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AI Summary
At Trend Health Partners, a tech-enabled payment integrity company, our mission is to facilitate collaboration between payers and providers for mutual benefit and waste reduction, ultimately improving access to healthcare. We achieve this by aligning the common goals of payers and providers and fostering collaboration through a shared technology platform and seamless workflows.
Joining Trend Health Partners means becoming a part of a dynamic growing organization that promotes a collaborative and innovative work environment. Our comprehensive compensation package includes competitive salaries, highly valued health insurance, a 401(k) plan with employer match, paid parental leave, and more.
The primary responsibility of the Medical Director is to provide physician-level clinical oversight, strategic guidance, and escalation support across DRG validation, HBA (hospital bill audit), IBR (itemized bill review), Clinical appeals, Readmissions/data mining, and Payer-facing clinical discussions.
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- Appeals work.
- Peer-to-peer review of individual claims
- Analyze appeal outcomes and make improvements to our concepts/review guidelines.
- Signoff on our clinical validation concepts as well as our coding concepts
- Provide thorough review of each concept and the supporting references
- As needed input for QA reviews
• APR-DRG and MS-DRG methodology
• Clinical validation
• Coding vs clinical criteria distinctions
• Readmissions logic
• Denials and appeals strategy
• Inpatient medical necessity
• Appeals leadership (experience in payer / provider appeals and external reviews
• Client facing experience
• Navigate payer / provider friction
- This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.
- The nature of the work is sedentary, and the employee will be sitting most of the time.
- Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.
- Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.
- This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required.
- Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.
- Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.
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