Overall case guidance and consulting to ensure that fraud, waste, and abuse efforts are performed with the highest and most current clinical standards
Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on services provided to members
Perform reviews and participate in peer-to-peer discussions of inpatient DRG Clinical Validation audits and appeals
Serves as a resource for information and consultation on the issues related to utilization management and clinical services
Approval and direction of consultant reviews. Participation in and support of overpayment recoveries
Support as needed to internal and external agencies in conjunction with these reviews such as but not limited to the Special Investigations Unit
Review of services suspected of being performed for purposes not medically necessary. Appropriate documentation of decisions and follow-up
Comply with all state, federal, and regulatory requirements
Other duties as necessary to ensure progression and completion of reviews
Participate on projects and committees as necessary

MD or DO with an unrestricted FL medical license
3+ years of experience in active clinical practice (primary care specialty desirable)
Excellent written and verbal communication skills with the ability to interact with all levels of the organization, external customers and providers
Ability to analyze data, measure outcomes, and develop action plans
Ability to intervene in crisis situations and multi-task
Conversant with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement.
Experience in utilization management, case review, and/or quality improvement activities in a managed care setting.

Medical Director – Payment Integrity Officer

Key skills