Medical Director, Payer Clinical Services

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Trend Health Partners

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2018

🏥 Healthcare

⚕️ Healthcare Insurance

💳 Fintech

💰 Private Equity Round on 2023-01

Healthcare • Healthcare Insurance • Fintech

Trend Health Partners is a healthcare technology company focused on enhancing payer-provider collaboration to improve financial management in healthcare. By leveraging AI-enabled technology, Trend Health Partners offers solutions to reduce credit balances, minimize payment denials, and ensure payment accuracy, ultimately fostering better relationships among stakeholders in the healthcare ecosystem. With a commitment to neutrality and efficiency, they aim to reshape the healthcare financial landscape for the benefit of providers, payers, and patients alike.

📋 Description

• Provide physician-level clinical oversight, strategic guidance, and escalation support across DRG validation, hospital bill audit, itemized bill review, clinical appeals, readmissions/data mining, and payer-facing clinical discussions • Act as a clinical authority, payer relationship asset, escalation point, and strategic advisor to Clinical Services leadership • Perform appeals work • Conduct peer-to-peer review of individual claims • Analyze appeal outcomes and improve concepts and review guidelines • Sign off on clinical validation concepts and coding concepts • Thoroughly review each concept and its supporting references • Provide input for QA reviews as needed • Navigate payer/provider friction • Perform other duties as assigned • Complete compliance requirements requested by business partners, including potential background and drug screenings and disclosures of personal health information or personally identifiable information

🎯 Requirements

• Licensed MD • Thorough understanding of APR-DRG and MS-DRG methodology • Understanding of clinical validation • Understanding of coding versus clinical criteria distinctions • Understanding of readmissions logic • Understanding of denials and appeals strategy • Understanding of inpatient medical necessity • Experience in payer/provider appeals and external reviews • Appeals leadership experience • Client-facing experience • Ability to navigate payer/provider friction • Ability to work with computers and printers • Ability to perform typing and repetitive computer hardware/software use throughout the day • Ability to concentrate on analytical tasks, read information, and communicate verbally and in writing • May be required to complete business-partner compliance requirements, including background and drug screenings and disclosures of personal health information or personally identifiable information

🏖️ Benefits

• Competitive salaries • Health insurance • 401(k) plan with employer match • Paid parental leave