Senior Medical Director – Claims

TBC Corporation

About The Position

Lyric is an AI-first, platform-based healthcare technology company, committed to simplifying the business of care by preventing inaccurate payments and reducing overall waste in the healthcare ecosystem, enabling more efficient use of resources to reduce the cost of care for payers, providers, and patients. Lyric, formerly ClaimsXten, is a market leader with 35 years of pre-pay editing expertise, dedicated teams, and top technology. Lyric is proud to be recognized as 2025 Best in KLAS for Pre-Payment Accuracy and Integrity and is HI-TRUST and SOC2 certified, and a recipient of the 2025 CandE Award for Candidate Experience. . Interested in shaping the future of healthcare with AI? Explore opportunities at lyric.ai/careers and drive innovation with #YouToThePowerOfAI. The Senior Medical Director serves as a pivotal clinical leader within Lyric, providing strategic oversight for the development, validation, and continuous improvement of pre-payment edits to ensure robust payment integrity. In this capacity, the Senior Medical Director partners with executive leadership, clinical teams, and external stakeholders, acting as a trusted advisor on complex clinical scenarios and claims outcomes. As the primary liaison between Lyric and its customers, this role represents the organization in industry forums and payer-provider collaborations, fostering strong relationships and advancing Lyric’s reputation as an industry leader. The Senior Medical Director is also responsible for remaining at the forefront of evolving healthcare trends, regulatory requirements, and advancements in medical practice, ensuring that Lyric’s strategies and solutions consistently reflect best practices and support organizational objectives.

Requirements

Board-certified physician (MD or DO) with at least 10 years of active clinical experience, preferably in Internal Medicine, Family Practice or other related disciplines
3 or more years’ experience as a Medical Director for a health insurance payer
Deep understanding of disease processes, treatment modalities and evidence-based medicine
American Academy of Professional Coders (AAPC) Certified Professional Coders (CPC) certification or American Health Information Management Association (AHIMA) Certified Coding Specialist-Physician (CCS-P) is required or within 6 months of hire date
Familiarity with payer operations, claims adjudication, and payment integrity strategies.
Experience with utilization management, medical policy development, and regulatory compliance.
Ability to analyze complex clinical scenarios, claims data, and outcomes to inform policy and operational decisions
Strong critical thinking, strategic planning and problem-solving skills.
Proven leadership in clinical and cross-functional teams, including mentoring and guiding staff as necessary
Excellent verbal and written communication skills for interacting with executive
Ability to represent the organization in industry forums and payer-provider collaborations
Up-to-date understanding of healthcare regulations, payer policies and industry standards.

Nice To Haves

Strong Medical Director/CMO background with experience in health plan, payment integrity programs and claims management
Strong communication skills: verbal, written, and multi-media
Strong interpersonal/relationship skill
Personal, flexible, creative problem-solving style capabilities
Ability to project high energy and passion for the process, while sustaining a patient persistence in achieving realistic goal

Responsibilities

Assist the Clinical Development Department with pre-pay edit development, maintenance and communication of new edits (edit creation, removal, most common clinical scenarios, medical policy and medical necessity reviews, etc.) for all content areas.
Approve and provide clinical rationale, when developing editing concepts that depart from sourced material to Lyric created content edits.
Provide support to Product Strategy team regarding which edits do or don’t remain included Lyric content groups.
Participates in analytic review of clinical content/rules to evaluate trends and possible content/rule development opportunities.
Trusted advisor and industry expert responsible for understanding key healthcare issues and trends as well as competitive product offerings, translating these into new cutting-edge content solutions
Regularly interact with executives and customers as well as partner with major internal Lyric stakeholders (e.g. Customer Success, Go To Market, Client Executives, Analytics, Product Strategy, etc.)
Support any content calls with clients where medical director assistance is requested/preferred, On-site customer visits as requested
Facilitate Annual New CPT Code webinar and other ad-hoc customer webinars as necessary
Hosts bi-monthly content review call with client Medical Directors on various topics

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