Medical Director

This is a fully remote position, open to applicants in United States.

📋 Description

• Deliver clinical leadership and medical supervision for audit initiatives involving governmental and commercial payer claims.

• Analyze and interpret medical records, claims data, coding patterns, clinical documentation, and payer policies to ensure precise audit conclusions.

• Assess medical necessity, level of care, site of service, coding precision, documentation adequacy, and compliance with relevant clinical standards and payer demands.

• Contribute to audit methodologies, clinical validation frameworks, sampling strategies, and quality assurance processes to guarantee consistency, defensibility, and adherence to regulations.

• Leverage knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to inform audit results, provider education, and client outputs.

• Collaborate with audit operations, coding, clinical review, data analytics, compliance, legal, and client-facing teams to address complex clinical and payment integrity challenges.

• Provide physician-level review and assistance for disputes, rebuttals, grievances, appeals, and clinical explanations directed at providers.

• Engage in the creation and upkeep of clinical audit guidelines, review protocols, policy interpretation tools, and training materials for reviewers.

• Stay informed on regulatory updates, changes in payer policies, coding guidance, clinical practice trends, and audit risk areas that could impact governmental or commercial payer operations.

• Assist client engagements by clarifying clinical rationale, audit conclusions, documentation requirements, and defensible review standards.

• Foster clinical accuracy, reviewer consistency, ethical audit practices, and ongoing enhancement across medical review operations.

• Perform other related duties as assigned by executive leadership.

⛳️ Requirements

• A medical degree (MD or DO) is required.

• An active, unrestricted medical license in good standing is required; willingness to acquire additional licensure may be preferred based on business needs.

• Board certification in an ABMS or AOA-recognized specialty is preferred.

• A minimum of 5+ years of direct clinical patient care experience following residency or fellowship is required; experience in inpatient, post-acute, emergency medicine, hospital medicine, internal medicine, surgery, or a payer-relevant specialty is preferred.

• Experience with governmental payer programs, including Medicare, Medicaid, and/or Medicare Advantage, is strongly preferred.

• Familiarity with commercial payer policies, managed care operations, utilization management, medical necessity review, claims audit, coding review, appeals, or payment integrity is preferred.

• No current sanctions, exclusions, or restrictions from federal or state governmental healthcare programs.

• Previous experience in an audit firm, payer organization, payment integrity vendor, utilization management organization, or a highly regulated healthcare setting is strongly preferred.

🏝️ Benefits

• Equal Employment Opportunity at Machinify

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