Medical Director (Clinical Chart Validation Team)

Overview

The Medical Director (MD) is a key member of the audit, quality assurance and client team. The Medical Director is responsible for representing the team on all audit and appeals decisions. The Medical Director 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 CCV inpatient audit, documentation, and communication of results.

Responsibilities

• Inpatient Audits (Prepayment & Retrospective)
• Performs billing and coding audits to ensure charges are supported by the appropriate clinical documentation, review medical records, and document findings in Cotiviti and client systems as necessary.
• Conducts reviews of medical records, charges and associated documentation, researching and applying knowledge related to billing and coding guidelines searching for billing, coding and unsupported (or clinical) documentation in provider billing. Analyzes medical record documentation to determine the accuracy and completeness of clinical and coding information in support of correct claim coding and billing guidelines.
• Manages the workflow and deadlines to ensure accuracy and timeliness of audit results are consistent with client, federal, and state rules, regulations, and guidelines as applicable.
• Upholds HIPAA privacy and security guidelines.
• Appeals administration and oversight
• Conduct audit of appeals on claims originally recommended for changes by another CCV Auditor to uphold or overturn the original audit decision.
• Review new support evidence and/or documentation and gather other information as needed.
• Participate in client and provider meetings to review and discuss audit case findings and results.
• Research and Development
• Assist the Clinical Audit Manager and Research Department to develop medical policy edits.
• Develop scorecards for existing rules-based logic to analyze trends in current rules-based audit selection criteria and recommend ongoing optimization.
• Quality Assurance Program support
• Participate in the design and implementation of the QA program and provide support for ongoing quality assurance audits for interrater reliability and coding accuracy.
• Support new sales activity and existing client growth by identifying value creation opportunities for our clients.
• Other duties as assigned.

 Other Related Responsibilities

• Delivers personal assignments reliably and on-time through organized personal work processes.
• Produces quality work that considers the client’s (internal and external) needs and qualitative self-review process.
• Exhibits behaviors consistent with …