Medical Policy Director

Overview The Medical Policy Director (MPD) is a key member of the Go To Market team. Along with the Client Engagement Leader, Client Medical Director (CMD), the MPD co-captains the team serving the Prospective Payment Management (PPM) client team at the health plan. The MPDs role is to serve as a coding and medical payment policy subject matter expert (SME), with the assistance of a CMD. The MPD is responsible for directing the Medical Policy Committee (joint committee with health plan MD, coding experts, and payment integrity). The MPD will develop a relationship with the client, review their data, select medical policy to present, serve as SME for clinical and coding expertise, and back-end support for Cotiviti ’s and the client’s Medical Directors. The MPD will evolve as the trusted advisor for the Health Plan in terms of medical payment policy. Responsibilities Act as a knowledgebase expert regarding the Cotiviti Medical Policy library. Gain an understanding of each client’s unique lines of business, medical policy standards and system configuration strategy to inform optimization opportunities. Analyze client data and identify new medical policy opportunities for presentation including valuation and validation of editing. Examine and select specific claim examples to utilize in a presentation to the client to support the understanding of the new medical policy. Prepare various documents and presentation materials for use during internal payment policy committee meetings and/or client meetings. Review all documents and coordinate reviews with the CMD to evaluate and validate the editing and financial impact. Confidently perform client policy presentations to highlight the facts of each rule, the data that supports the policy recommendation, the impact to claims processing, and the associated value. Successfully advocate for the adoption of new medical policies by clients to optimize the value Cotiviti offers. Participate in client meetings as required as a medic