Medical Director - Contract presso CorVel Corporation

This position will provide medical expertise as a consultant in the development and review of claims review policy. This individual will support CERIS’s application of CMS, client and industry standing billing guidelines in circumstances included by not limited to: peer to peer reviews, arbitrations, administrative law hearings and/or mediations by illustrating the relationship between the guidelines CERIS applies to claims review with clinical practice. Drive CERIS’s best practice policies toward consistent and innovative claim review.

This is a part-time contract role.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Assist with development and research of reimbursement and/or clinical policies that affect CERIS reviews including itemized bill review and DRG.
• Proactively maintain an awareness of current laws, statutes, regulations, etc. that impact healthcare operations, and assist in strategizing the application of those guidelines to CERIS reviews.
• Conduct peer to peer reviews on DRG claim reviews as needed
• Verbally communicate interpretation of CMS, Federal, State and client policies to providers and clients as needed.
• Analyze and review items disallowed by CERIS are consistent with CMS published guidelines on an annual basis.
• Serve as a witness in legal proceedings such as arbitration, bench trials or mediation to support CERIS reviews.

KNOWLEDGE & SKILLS:

• Knowledge of nationally recognized criteria (e.g., Milliman, Interqual etc.), medical necessity and benefit interpretation for both ambulatory and inpatient care.
• Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format.
• Understanding of general health plan and regulatory requirements for utilization management, denials and appeals.
• Strong understanding of healthcare revenue cycle and claims reimbursement.
• Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative.

EDUCATION/EXPERIENCE:

• Requires MD or DO from an accredited medical school
• Board Certification or Eligibility in a primary care specialty preferred
• A current and unrestricted medical license in at least one jurisdiction and willing to obtain additional license, if required.
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Experience in acute clinical care areas of facilities in OR, ICU, CCU, ER, Telemetry, Medical/Surgical, OB or L&D, Geriatrics and/or Orthopedics.
• 5+ yrs clinical practice
• 2+ yrs experience as a health plan Medical Director preferred
• 2+ yrs HMO/Managed Care experience

ABOUT CERIS:

CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). 

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.