Research Medical Director (Medicaid Medical Policy)

Overview: The Research Medical Director is a key member of the Clinical and Policy research development area at Cotiviti. The Research Medical Director is responsible for providing leadership guidance to the clinical teams and ensuring the Rules and policies are accurately interpreted and developed. This role is also responsible for analyzing, interpreting, and developing additional policies that will allow us to enhance our medical policy library. The Medical Director will guide both internal and external processes as related to PPM polices and rules. This is a full-time role and can work remotely in the US. Responsibilities: • Interpret and assess payment policy and medical coding information / guidelines against our policy library for maintenance of existing policy and development of new policy. • Conducts thorough research and analysis for medical policy items. • Performs multi-faceted analytics for data and report analysis. • Responsible for translating industry references into Cotiviti policy. • Reviews and identifies changes to medical policies in order to maintain an accurate and current medical policy library. • Identifies new opportunities as appropriate from both clinical reference and analytical sources. • Analyze research inquiries from a multitude of sources and apply solid clinical judgment to determine potential impact to medical policies. • Ability to determine if an update to existing policy logic or content is warranted based on changes to industry. Perform QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to the originator as needed. • Educates client-facing MDs and Client Policy Managers (CPMs) on new changes and policy updates by actively participating in monthly meetings for client facing MDs and CPMs. • Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes. • Maintains current knowledgebase of industry and content, best practices, applications, procedures and policies. • Complete all responsibilities as outlined in the annual performance review and/or goal setting. • Complete all special projects and other duties as assigned. • Must be able to perform duties with or without reasonable accommodation. This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change. Qualifications: • MD or DO degree (required). Additionally, an MBA degree is preferred. • 10+ years of Research experience. • Knowledge of healthcare payers, policy payment and correct coding knowledge (preferred). • Possess in depth knowledge of claims, claims adjudication, medical policy rules and edits. • Strong organizational and project management experience preferred. • Proven success as a manager in a scalable organization that has significant scope, complexity and breadth. • Strong personal leadership – in terms of the role of a leader, the impact on the company and creating. • momentum for culture and accelerating the strategy. • Relationship development skills to forge positive and lasting relationships with key business partners and clients. • Ability to achieve sustainable results through others, including the development and assignment of other MDs and administrative staff as leaders, mentors, trainers, etc. Mental Requirements: • Ability to work well independently and in a team environment. • Ability to handle multiple tasks, prioritize and meet deadlines. • Highly organized. • Excellent written and verbal communication skills, strong listening skills. • Ability to work in a fast paced, entrepreneurial environment with a strong bias for deep analysis, timely action and thorough execution. • Understanding of and ability to lead and manage in a matrix environment where team work is essential. • Ability to make good decisions that are strategically relevant to the company’s goals and objectives. Physical Requirements and Working Conditions: • Remaining in a stationary position, often standing or sitting for prolonged periods. • Repeating motions that may include the wrists, hands and/or fingers. • Must be able to provide a dedicated, secure work area. • Must be able to provide high-speed internet access / connectivity and office setup and maintenance. Base compensation ranges from $225,000 to $275,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration. Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page. Date of posting: 08/04/2025 Applications are assessed on a rolling basis. We anticipate that the application window will close on 10/04/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected. #LI-JB1 #LI-Remote #director Apply tot his job