Medical Director

Key Responsibilities

• Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
• Review and interpret medical records, claims data, coding patterns, clinical documentation, and payer policies to support accurate audit determinations.
• Evaluate medical necessity, level of care, site of service, coding accuracy, documentation sufficiency, and alignment with applicable clinical standards and payer requirements.
• Support audit methodologies, clinical validation frameworks, sampling approaches, and quality assurance processes to ensure consistency, defensibility, and regulatory alignment.
• Apply knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to audit findings, provider education, and client deliverables.
• Partner with audit operations, coding, clinical review, data analytics, compliance, legal, and client-facing teams to resolve complex clinical and payment integrity issues.
• Provide physician-level review and support for disputes, rebuttals, grievances, appeals, and provider-facing clinical explanations.
• Participate in the development and maintenance of clinical audit guidelines, review protocols, policy interpretation tools, and reviewer training materials.
• Monitor regulatory updates, payer policy changes, coding guidance, clinical practice trends, and audit risk areas that may affect governmental or commercial payer work.
• Support client engagements by explaining clinical rationale, audit findings, documentation expectations, and defensible review standards.
• Promote clinical accuracy, reviewer consistency, ethical audit practices, and continuous improvement across medical review operations.

Knowledge, Skills and Abilities

• Strong understanding of governmental and commercial payer operations, including Medicare, Medicaid, Medicare Advantage, managed care, and employer-sponsored health plan environments.
• Demonstrated ability to interpret payer policies, medical necessity criteria, clinical guidelines, coding standards, and documentation requirements.
• Knowledge of claims adjudication, payment integrity, utilization management, risk adjustment, fraud/waste/abuse concepts, and audit operations.
• Ability to synthesize complex clinical, coding, and claims information into clear, defensible medical opinions and audit rationales.
• Strong written and verbal communication skills, including the ability to support client discussions, appeals, provider education, and internal reviewer guidance.
• Experience collaborating with coding professionals, nurse reviewers, data analysts, compliance leaders, legal teams, and payer stakeholders.
• Comfortable working in a structured audit environment with expectations for consistency, accuracy, timeliness, and regulatory defensibility.
• Commitment to ethical review practices, clinical integrity, confidentiality, and objective application of evidence-based standards.

Required and Preferred Qualifications

• Medical degree (MD or DO) required.
• Active, unrestricted medical license in good standing required; willingness to obtain additional licensure may be preferred based on business needs.
• Board certification in an ABMS or AOA-recognized specialty preferred.
• Minimum of 5+ years of direct clinical patient care experience post-residency or fellowship required; experience in inpatient, post-acute, emergency medicine, hospital medicine, internal medicine, surgery, or a payer-relevant specialty preferred.
• Experience with governmental payer programs, including Medicare, Medicaid, and/or Medicare Advantage, strongly preferred.
• Experience with commercial payer policies, managed care operations, utilization management, medical necessity review, claims audit, coding review, appeals, or payment integrity preferred.
• No current sanctions, exclusions, or restrictions from federal or state governmental healthcare programs.
• Prior experience in an audit company, payer organization, payment integrity vendor, utilization management organization, or highly regulated healthcare environment strongly preferred.