Medical Director – Prior Authorization

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☕ Washington – Remote

☕ Washington – Remote

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Virtix Health

WebsiteLinkedInAll Job Openings

11 - 50 employees

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare Insurance • Technology • Wellness

Virtix Health is a company that partners with health plans across the country to enhance clinical, financial, and operational outcomes. They offer a variety of services, including virtual wellness visits, in-home health risk assessments, retrospective chart review, workflow technology, and patient engagement services. They specialize in risk adjustment coding and clinical data connectivity, providing technology solutions that automate data acquisition and improve the management of medical records. Their aim is to innovate how healthcare data is exchanged to elevate the performance of health plans of all sizes.

📋 Description

• Seeking a highly skilled and detail oriented Medical Director to join our team. • The Medical Director will play a critical role in assessing the quality of clinical services provided to Medicare beneficiaries ensuring compliance with clinical guidelines and regulations while helping to drive improvements in care delivery. • After completion of mentored training, daily work includes reviewing and analyzing clinical records, charts and case files to ensure that all clinical practices, treatments and services provided to Medicare beneficiaries meet the highest standards of care and adhere to CMS regulations, policies and procedures. • Conduct regular reviews to monitor the appropriateness of care provided to beneficiaries and recommend any necessary interventions or adjustments need to align with CMS National and Local Coverage Determinations (NCD/LCD) • Prepare for and participate in peer-to-peer discussions with providers and suppliers to review clinical documentation, discuss coverage criteria, and address questions related to prior authorization requests. • Assist in the training and development of clinical teams on CMS NCD/LCD guidelines, clinical documentation and compliance. • Provide recommendations for improvements in clinical practices based on findings from record reviews, data analysis, and best practices in the field. • Participate in the development and implementation of quality improvement initiatives to enhance care delivery and achieve CMS performance goals. • Maintain accurate and up to date records of all clinical reviews, audits and quality improvement efforts.

🎯 Requirements

• Be a board-certified clinician, including a Doctor of Medicine or a Doctor of Osteopathy identified by an individual NPI in a specialty recognized by the American Board of Medical Specialties • Anesthesiologists or those with a completed fellowship in pain management are strongly preferred OR be associated with a primary specialty designation that aligns with PMR, neurology, pulmonology, urology, or orthopedics. • Board certified for at least 3 years; Currently hold an active, valid and unrestricted license to practice medicine in at least one U.S. state, territory, or the District of Columbia. • Must not be excluded from participating in Medicare, Medicaid or the Children’s Health Insurance Program. • State of Washington license to practice medicine preferred or willingness to obtain. • Utilization management experience preferred. • Excellent communication skills (both verbal and written) with the ability to collaborate effectively with diverse healthcare teams. • Familiarity with electronic health records (EHR) and documentation and coding practices (ICD-10, CPT) • Knowledge of CMS regulations and Medicare requirements. • Strong attention to detail and organizational skills to manage multiple tasks and priorities. • Ability to work in a fast paced, deadline driven environment.

🏖️ Benefits

• Quality of life with a remote predictable, full-time schedule • Comprehensive training and education program • Opportunities for career growth within the organization • Medical, Dental, Vision coverage • 401K • Holidays, paid time off • long-term disability insurance • life insurance • Allowance for CME and/or license renewals