Medical Director

Clinical Leadership and Oversight:

• Serve as clinical subject matter expert and physician leader for audit programs.
• Review medical records, claims data, and coding patterns to support accurate audit determinations.
• Evaluate medical necessity, site of service, and alignment with payer policies and regulations.

Collaboration and Communication:

• Partner with audit operations, coding, data analytics, compliance, and legal teams to resolve complex issues.
• Provide physician-level support for disputes, appeals, and provider education.
• Support client engagements by explaining clinical rationale and defensible review standards.

Regulatory and Operational Excellence:

• Monitor regulatory updates, payer policy changes, and clinical practice trends affecting audit work.
• Develop and maintain clinical audit guidelines and reviewer training materials.
• Promote clinical accuracy, reviewer consistency, and ethical audit practices across operations.