The
Medical Director serves as a clinical subject matter expert and physician leader for an audit organization supporting governmental and commercial payer programs. This role provides medical oversight for audit strategy, clinical review methodologies, coding and documentation interpretation, claims validation, medical necessity determinations, and appeal support. The Medical Director ensures that audit findings are clinically sound, evidence-based, consistently applied, and aligned with applicable payer policies, contractual requirements, CMS guidance, Medicaid program requirements, Medicare Advantage standards, commercial plan policies, and relevant federal and state healthcare regulations. The Physician hired for this role will join a team of other Medical Directors, all reporting to the Executive Medical Director at Machinify.
Key Responsibilities:- Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
- Review and interpret medical records, claims data, coding patterns, clinical documentation, and payer policies to support accurate audit determinations.
- Evaluate medical necessity, level of care, site of service, coding accuracy, documentation sufficiency, and alignment with applicable clinical standards and payer requirements.
- Support audit methodologies, clinical validation frameworks, sampling approaches, and quality assurance processes to ensure consistency, defensibility, and regulatory alignment.
- Apply knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to audit findings, provider education, and client deliverables.
- Partner with audit operations, coding, clinical review, data analytics, compliance, legal, and client-facing teams to resolve complex clinical and payment integrity issues.
- Provide physician-level review and support for disputes, rebuttals, grievances, appeals, and provider-facing clinical explanations.
- Participate in the development and maintenance of clinical audit guidelines, review protocols, policy interpretation tools, and reviewer training materials.
- Monitor regulatory updates, payer policy changes, coding guidance, clinical practice trends, and audit risk areas that may affect governmental or commercial payer work.
- Support client engagements by explaining clinical rationale, audit findings, documentation expectations, and defensible review standards.
- Promote clinical accuracy, reviewer consistency, ethical audit practices, and continuous improvement across medical review operations.
- Other related job duties, as assigned by executive leadership.
Knowledge, Skills and Abilities Needed:- Strong understanding of governmental and commercial payer operations, including Medicare, Medicaid, Medicare Advantage, managed care, and employer-sponsored health plan environments.
- Demonstrated ability to interpret payer policies, medical necessity criteria, clinical guidelines, coding standards, and documentation requirements.
- Knowledge of claims adjudication, payment integrity, utilization management, risk adjustment, fraud/waste/abuse concepts, and audit operations.
- Ability to synthesize complex clinical, coding, and claims information into clear, defensible medical opinions and audit rationales.
- Strong written and verbal communication skills, including the ability to support client discussions, appeals, provider education, and internal reviewer guidance.
- Experience collaborating with coding professionals, nurse reviewers, data analysts, compliance leaders, legal teams, and payer stakeholders.
- Comfortable working in a structured audit environment with expectations for consistency, accuracy, timeliness, and regulatory defensibility.
- Commitment to ethical review practices, clinical integrity, confidentiality, and objective application of evidence-based standards.
Required and Preferred Qualifications- Medical degree (MD or DO) required.
- Active, unrestricted medical license in good standing required; willingness to obtain additional licensure may be preferred based on business needs.
- Board certification in an ABMS or AOA-recognized specialty preferred.
- Minimum of 5+ years of direct clinical patient care experience post-residency or fellowship required; experience in inpatient, post-acute, emergency medicine, hospital medicine, internal medicine, surgery, or a payer-relevant specialty preferred.
- Experience with governmental payer programs, including Medicare, Medicaid, and/or Medicare Advantage, strongly preferred.
- Experience with commercial payer policies, managed care operations, utilization management, medical necessity review, claims audit, coding review, appeals, or payment integrity preferred.
- No current sanctions, exclusions, or restrictions from federal or state governmental healthcare programs.
- Prior experience in an audit company, payer organization, payment integrity vendor, utilization management organization, or highly regulated healthcare environment strongly preferred.
