Senior Medical Director – Claims

🕒 January 23

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Lyric - Clarity in motion.

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

💳 Fintech

☁️ SaaS

Healthcare Insurance • Fintech • SaaS

Lyric is a leading healthcare technology company focused on payment integrity and accuracy solutions. With over 30 years of experience, Lyric aims to simplify the business of care by leveraging machine learning and predictive analytics to empower health plan payers. The company provides a range of solutions, including Lyric 42 Platform, Pre-Pay Editing, Diagnostics Module, Coordination of Benefits, Concept Libraries, and LyricIQ, which combines AI-powered payment accuracy services. Additionally, Lyric focuses on transparency and responsibility in technology development, ensuring enhanced payment accuracy, administrative efficiencies, and reduced provider abrasion. As a trusted partner in the healthcare industry, Lyric continues to deliver cutting-edge technologies at the crossroads of healthcare and fintech, supporting health plans and providers in the shift to value-based care.

📋 Description

• 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

🎯 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.

🏖️ Benefits

• Lyric is an Equal Opportunity Employer that strives to create an inclusive environment, empower employees and embrace collaborative success.