Medical Director - Payment Integrity Services

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    "ShortDescriptionStr": "As Medical Director – Payment Integrity at EXL Health, you sit at the intersection of clinical practice, payor operations, and financial stewardship.  You leverage your clinical expertise, managed care experience, and deep understanding of payer guidelines, regulatory requirements, and industry-standard policies to ensure claims are paid accurately, appropriately, and in full compliance with state, federal and plan-specific policies.   In this role, every decision influences how healthcare dollars are safeguarded and allocated, making you a key clinical authority within EXL’s Payment Integrity team.  ",
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    "ExternalDescriptionStr": "<p>Salary Range: &nbsp;$215,000 - $290,000</p>\n<p>Potential travel estimated at less than 10% and based on business need.</p>\n<p>&nbsp;</p>\n<p>As Medical Director – Payment Integrity at EXL Health, you sit at the intersection of clinical practice, payor operations, and financial stewardship.&nbsp; You leverage your clinical expertise, managed care experience, and deep understanding of payer guidelines, regulatory requirements, and industry-standard policies<strong>&nbsp;</strong>to ensure claims are paid accurately, appropriately, and in full compliance with state, federal and plan-specific policies.<strong>&nbsp;&nbsp;</strong> In this role, every decision influences how healthcare dollars are safeguarded and allocated, making you a key clinical authority within EXL’s Payment Integrity team.&nbsp;</p>\n<p>You collaborate closely with senior leaders, analytics partners and Operations teams to connect clinical insight with business strategy.&nbsp; When coding changes, regulatory updates, or new data patterns emerge, you help interpret their clinical impact and shape how our payment integrity programs respond, contributing to the evolution of new concepts and solutions.&nbsp;</p>\n<p>&nbsp;</p>",
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    "ExternalQualificationsStr": "<ul><li>MD or DO degree from an accredited institution </li><li>5+ years of post‑residency or post‑fellowship clinical experience, ideally including inpatient care and/or work with Medicare or Medicare‑like populations </li><li>Current, active Board Certification through an ABMS‑recognized medical specialty </li><li>Proven experience applying national clinical guidelines (e.g., MCG®, InterQual®) within medical management or utilization review settings </li><li>Exceptional written and verbal communication skills, with the ability to translate clinical concepts for diverse audiences </li><li>Demonstrated analytical and interpretive ability, with experience collaborating on teams focused on quality management, utilization management, case management, discharge planning, or post‑acute care services (e.g., inpatient rehab, home health) </li><li>Unrestricted medical license in at least one U.S. jurisdiction, with the ability and willingness to obtain additional state licensure as needed </li><li>No sanctions from federal or state agencies; able to meet and maintain all EXL credentialing standards </li></ul><p><strong>Preferred Qualifications</strong></p><ul><li>In‑depth knowledge of the managed care ecosystem, including Medicare Advantage, Managed Medicaid, Commercial insurance, integrated delivery systems, and medical management operations </li><li>Utilization management experience within a medical management organization such as Medicare Advantage, Managed Medicaid, or Commercial payer environments </li><li>Clinical background in Internal Medicine, Hospital Medicine, Family Practice, Geriatrics, or Emergency Medicine </li><li>Advanced degree (MBA, MHA, MPH) demonstrating additional expertise in health administration, public health, or business disciplines </li><li>Experience in public health, population health, healthcare analytics, or familiarity with business metrics and data‑driven performance measures</li></ul>",
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    "ExternalResponsibilitiesStr": "<p>Day to day, you turn clinical expertise into actionable guidance for payment integrity programs. You help design and refine pre‑pay and post‑pay review workflows, clinical audits, coding integrity initiatives, and fraud, waste, and abuse reviews, while reviewing complex cases and supporting criteria and policy development so that our determinations are clinically sound, defensible, and practical.</p><p>You also play a visible client‑facing role by participating in client, sales, and marketing meetings. You explain how our payment integrity programs work in clinical terms, clarify determinations and guidelines, and support RFPs, finalist presentations, and governance discussions, speaking comfortably with medical leaders, provider representatives, and non‑clinical executives.</p><p>Inside EXL, you are a coach and resource for clinicians working in Payment Integrity. You guide nurses, physicians, and reviewers on challenging cases and appeals, collaborate with Compliance and Accreditation teams to ensure policies and documentation meet regulatory expectations, and support internal education to build payment integrity knowledge across clinical and non‑clinical teams.</p><p>This role is ideal for a physician who enjoys where practice meets operations. Your background in managed care, utilization management, and ideally payment integrity equips you to assess medical necessity, level of care, and documentation with confidence, while your ability to interpret data, communicate clearly, and work in a matrixed environment helps you drive meaningful improvements in payment decisions at scale.</p>",
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