Medical Director, Payment Integrity & Clinical Disputes

Company: Michael Hill, MD and Associates (MHMDAA) Reports to: Chief Executive Officer (CEO) Category: Utilization Management / Physician Advisory / Payer Relations Work Volume: Part-time (Minimum 0.5 FTE) to Full-time  Company Description Michael Hill, MD and Associates is a premier medical advisory firm specializing in the rigorous, independent assessment of high-stakes healthcare payor-provider disputes. We serve as a critical bridge in the litigation landscape, providing objective clinical and administrative opinions for active claim disputes between hospital providers and insurance payers. Our expertise is focused on the granular review of medical necessity determinations and the clinical validity of payer denials across the entire revenue cycle. By evaluating the appropriateness of actions related to prior authorization, clinical coding, claim submission integrity, and technical denial management, we deliver evidence-based insights that bring clarity to complex reimbursement litigation. Role Description The Medical Director for Payment Integrity & Clinical Disputes serves as the clinical authority in the development of adjudication reports involving high-level clinical and administrative payment disputes. Reporting directly to the CEO as a member of a multidisciplinary care team, you will represent MHMDAA by providing independent review and expert opinion reports on complex reimbursement claim disputes involved in active litigation. This role requires a sophisticated command of medical necessity, Clinical Documentation Improvement (CDI), and the interplay between clinical care and contractual obligations. Core Responsibilities Dispute Resolution & Opinion Development: Lead the review and analyze the development of complex clinical reports and expert opinions for disputed claims. This includes cases involving: Inpatient vs. Observation status (including Two-Midnight Rule and Medicare Advantage program rule compliance). Level of care assignments (ICU vs. ICU-Intermediate). Assertions of "DRG Creep" and "ED Facility Level Creep." (DRG up coding) Review of pre/post-payment line-item disallowance results, including unbundling rules consistent with payer-specific Payment Integrity programs. Technical Denials (Untimely filing, COB, experimental) Audit Validation: Independently determine the accuracy of and provide expert opinions on previously completed Clinical Validation Audits and ED Facility Level Determinations. Audit Validation: add "as drafted by Nurse Reviewers" or similar Litigation Support: Synthesize clinical findings into authoritative reports that stand up to legal scrutiny in active payer-provider dispute litigation. Required Prior Experience Review and analyze administrative denials including, but not limited to, authorization, notification, timely filing, medical-records requests, and eligibility/coverage denials. Expert Peer-to-Peer (P2P) Advocacy: Significant experience conducting P2P discussions with payer medical directors or provider physician advisors. Ability to articulate clinical rationales based on severity of illness and intensity of service. Concurrent Review & Prevention: Background in partnering with hospital case management and UR teams to ensure real-time documentation reflects patient acuity and mitigates denial risks. Strategic Policy & Contractual Analysis: Experience evaluating payer medical policies against national standards (MCG/InterQual) to identify "gray areas." Experience advising Managed Care Contracting teams on clinical language to ensure fair and enforceable "Definitions of Medical Necessity." Provider Education: Proven track record of using dispute trends to educate stakeholders on documentation requirements and evidence-based medicine to reduce audit exposure. Qualifications Education: MD or DO degree from an accredited school of medicine. Board Certification: Current Board Certification in a clinical specialty (preferred) . Clinical Experience: Minimum of 5 years of post-residency direct patient care experience. Specialized Expertise: Must meet at least one: 3+ years as a Hospital Physician Advisor focused on UR and Denials. 3+ years as a Payor Medical Director with experience in UM and appeals . Utilization Management: Extensive, documented experience in Concurrent Review and P2P negotiations. Regulatory Knowledge: Deep mastery of CMS regulations, NCQA standards, and the application of both MCG and InterQual criteria. Key Competencies Evidence-Based Mastery High fluency in current clinical guidelines (e.g., AHA, ACC, IDSA) to challenge or defend provider/payer policies. Analytical Fluency Ability to interpret "big data" trends in denial patterns to identify and remediate systemic revenue leakage. Regulatory & Contractual Expertise Expert knowledge of CMS and Medicare Advantage (Part C) rules, state-specific prompt payment statutes, and administrative law. Clinical Integrity Ability to provide objective, independent clinical opinions that stand up to regulatory and legal scrutiny.

Created: 2026-03-04