Medical Director

Top Healthcare Company is hiring a North Carolina Licensed Physician to work as a Medical Director!

Must Have a current and active North Carolina Physician License.

100% Remote role!

Contract for one Year to start!

JOB DESCRIPTION

Process, adjust or update various moderate to complex claims payments and payment errors for any business segment and/or

claims-provider type

Respond promptly and accurately to inquiries from Customer Service Professionals, subscribers, providers, physicians and

other insurance carriers regarding claims payments.

Meet or exceed established quality and performance standards

Determine suspended claim resolution methods by reviewing benefit eligibility, claims history and other information

Escalate claims requiring specialized resolution to subject matter experts based on department policies and guidelines to

ensure the resolution Understand business requirement for the customer and provider segments with tailored solutions to their needs

Identify system issues by documenting the issue, recommend potential solution and refer appropriate technical staff

Work with designated Provider Services specialists to deliver services tailored to the provider services

Review claims for possible "fraud and abuse" and send to Special Investigations Unit for additional investigation

Use continuous improvement and knowledge of claims to drive efficiency and production gains; share best practices

Coordinate with other insurance carriers and Medicare to determine of Company's payment liability

Represent Claims interests on divisional or enterprise project teams

The application of a Medical Director's knowledge and clinical skills will vary across the Health Care division, dependent on focus areas identified by the business area supported.

Leadership Skills:

Project planning and management

Core Skills:

*Strategy

Develops, collaborates and/or drives strategy and approach for varied Health Care and/or organizational initiatives (i.e. sales management strategies, behavioral health strategies, new health care delivery strategies)

*Operations

Medical reimbursement and policy

Care management (utilization management, case management, PA, appeals)

Healthcare programs (disease management, Moonshots)

Network support (Credentialing)

Quality model design and analysis

*Partnership

Develop strategic partnerships with internal business partners and external clients to support value based agreements and drive better consumer and provider experience.

Takes a lead role in outreach and relationship building across the community (i.e. providers, health systems, community partners, members, etc).

Evaluate and manage new and/or existing vendors and solution partners to align to Company's strategic direction

Ongoing provider engagement functions

*Data gathering, management and analysis

Evaluate clinical and other data to identify opportunities for improvement in health outcomes and financial performance

Discuss data and performance with providers, employers, accreditors and regulators as needed.

*Communications

Represent company through delivery of presentations, speaking engagements and leadership of advisory groups with external audiences related to health care transformation and initiatives.

Publish high impact content focused on improving accessibility, quality and affordability.

*Innovation

Payment model design

Identify market trends that should influence key investments (new technologies, best practices).

Evaluation of investment/partnership opportunities

Hiring Requirements

*MD or DO from an accredited medical school and completion of residency training program.

*7+ years of experience in related field

*Some relevant experience outside of clinical practice is also required

*Current North Carolina medical license

*Board certification in ABMS/AOA recognized clinical specialty is required

Schedule

8-5 EST M-F with a Weekend Rotation

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on us.fitly.work.




Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).




This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.