Medical Director (Remote)

Availity • Remote, OR

415d • Remote

About The Position

The Medical Director at Availity will lead a team of Utilization Management (UM) RN Analysts in the development of the Auth AI platform. This role involves overseeing the interpretation of payer medical policy guidelines and ensuring the clinical validation of the platform. The Medical Director will collaborate with clinical and engineering teams to enhance the platform's capabilities, focusing on medical necessity criteria and prior authorization practices.

Requirements

• MD/DO with at least 8 years of clinical experience.
• At least 5 years of experience in healthcare revenue cycle roles including Utilization Management and prior authorization.
• Experience with claims appeals/denials, either with an insurer or healthcare provider.
• In-depth knowledge of utilization management principles and medical necessity guidelines.
• Strong analytic reasoning skills and excellent communication abilities.

Nice To Haves

• Deep knowledge of the healthcare insurance industry and relevant regulations.
• Experience working with payer medical policy teams.
• Exceptional critical thinking and reasoning skills.
• Ability to synthesize complex problems and collaborate with diverse team members.
• Self-motivated with strong leadership and delegation skills.

Responsibilities

• Lead a team of UM RN Analysts in the development of Availity's Auth AI platform.
• Provide oversight and input on the interpretation of payer medical policy guidelines.
• Construct NLP/AI-enabled attestation trees reflecting medical necessity criteria.
• Collaborate with clinical and engineering teams to ensure effective product development.
• Ensure the flow of tasks related to medical policy creation, including tree creation and MD validation.
• Provide input to the NLP team to enhance the validity and accuracy of outputs.
• Serve as a clinical liaison to medical policy teams at current customers.

Benefits

• Competitive salary and bonus structure.
• Generous HSA company contribution.
• Healthcare, vision, and dental benefits.
• 401k match program available from day one.
• Unlimited PTO for salaried associates plus 9 paid holidays.
• Education reimbursement for furthering education.
• Paid Parental Leave for both birth and adoptive parents.
• Wellness reimbursement up to $250/year for gym memberships and health programs.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Professional, Scientific, and Technical Services
• Education Level: Ph.D. or professional degree