Medical Director – Denials Management Full-Time Work from Home

Executives thrive with us! HCA Healthcare is one of the nation’s leading providers of healthcare services, comprising of over 180 hospitals and about 2,000 sites of care in 21 states and the United Kingdom. We are looking for a Medical Director for our Physician Advisory Group team where excellence creates excellence.

Benefits

Our positions offer a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as telemedicine services and free AirMed medical transportation.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
• Fertility and family building benefits through Progyny
• Free counseling services and resources for emotional, physical and financial wellbeing
• Family support, including adoption assistance, child and elder care resources and consumer discounts
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
• Employee Stock Purchase Plan
• Retirement readiness and rollover services and preferred banking partnerships
• Education assistance (tuition, student loan, certification support, dependent scholarships)
• Colleague recognition program
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

HCA Healthcare has expanded our influence across the healthcare industry by investing $3.5 billion in capital improvements in recent years. Do you want to be an influencer in healthcare? Apply for our Medical Director role today!

Job Summary and Qualifications

The Medical Director serves as a clinical resource and consultant to hospitals by providing identification, facilitation, and resolution of denials. The Medical Director will be responsible for timely completion of assigned peer to peers and documentation of the outcomes. The Medical Director will also provide physician education regarding accurate determination and documentation of the admission status/level of care and presence of complications or comorbidities.

ESSENTIAL JOB RESPONSIBILITIES:

• Conducts peer to peers with health plan counterpart for denied inpatient cases.
• Acts as a liaison with payers to facilitate approvals and prevent any denials. Facilitates, mentors, and educates other physicians regarding payer requirements.
• Performs data analysis related to utilization review (UR) metrics, works with hospital utilization management committees upon request to develop, implement, and monitor action plans related to denial reduction and authorization of level of care.
• Offers input on managed care contracting issues, best demonstrated practices, process improvement and utilization management activities, barriers to achieving goals and objectives of initiatives, and denials prevention initiatives.
• Demonstrates leadership, collaboration, and effective communication skills.
• Participate in the concurrent and retrospective appeal peer-review process. Provides oversight to the pre bill denial strategy within the payer process. Schedules and manages meetings with payer medical directors for collaboration and process improvement. Functions as a core team member of the denial management team. Educates physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.

REPORTS TO: VP Physician Advisor Peer to Peer Services

POSITION QUALIFICATIONS:

• Licensed (or eligible for licensure) Physician (MD/DO) in a state in the United States.
• Board Certification Required (Internal Medicine and Family Medicine preferred) Preferred ABQAURP HCQM Board Certification.
• Preferred work experience with the payors or as a physician advisor.

EDUCATION AND EXPERIENCE:

• Minimum of 5 years of experience in clinical practice.
• 3 years prior experience working for Payor, Physician Advisor or in a Leadership role.
• Knowledge of InterQual, Milliman or related evidenced based criteria sets.
• Familiar with Joint Commission, State and Federal standards/requirements, and DRG vs Per diem reimbursement models.
• Knowledgeable about third party payer source criteria of medical necessity.
• Organized and able to meet deadlines consistently.
• Computer experience required with skills including but not limited to Microsoft Windows, spreadsheets, and word processing.

HCA Healthcare is a comprehensive healthcare network where 280,000 people across more than 2,000 care facilities are all committed to creating a positive impact every day. It’s an organization that exists to give people healthier tomorrows. Our scale enables caregivers to deliver great outcomes for patients and gives colleagues unparalleled opportunities to learn and grow. Most importantly, as a part of HCA Healthcare we’re connected to something bigger, which means more resources, more solutions and more possibilities for everyone who walks through our doors. What matters most to our diverse and talented colleagues is giving people the absolute best healthcare possible. Every day, we seek to raise the bar higher, not just for ourselves, but for healthcare everywhere.

We offer an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO, medical, dental, flex spending, life, disability, tuition reimbursement, student loan repayment program, employee discount program and employee stock purchase program. We would love to talk to you about this fantastic opportunity.

“Bricks and mortar do not make a hospital. People do.”- Dr. Thomas Frist, Sr.HCA Healthcare Co-Founder

If you’re looking for a leadership opportunity that provides both personal satisfaction and professional growth, apply to join HCA Healthcare as a Medical Director. Unlock your leadership potential with HCA Healthcare.

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Tagged as: Denials, Denials Management