Managing Director – Physician Medical Director, D&E

Ankura is a team of excellence founded on innovation and growth.

Practice Overview
Ankura’s Healthcare practice advises healthcare companies, outside counsel and their clients on a wide variety of operational, clinical, legal, and regulatory matters. Our clients include academic medical centers, health systems, physician practice groups, post- and sub-acute providers, health plans and their delegates, pharmacies and pharmacy benefit management companies, as well as pharmaceutical, medical device, and diagnostics manufacturers. 

Position Expectations 
The expectation of this role is that the physician incumbent would be capable of supporting Ankura Healthcare clients with clinical knowledge and practice experience in using evidence based clinical guidelines. Additionally, expected from this role is the ability for the Physician to clearly and accurately communicate and explain complex clinical concepts consistent with their experience and supported clinical documentation and practice standards.

This role can be virtual or in a hybrid capacity.
 

Engagement Examples

The nature of the matters for which this position is involved include:

• Assist in-house and outside counsel during internal and externally driven investigations through the evaluation of medical records, the determination of medical necessity and appropriate medical coding, and the computation of financial impacts that may lead to repayments.

• Provide investigative assistance in matters involving research misconduct, human subjects’ protection, and financial fraud related to research.

• Assist clients with the Independent Review Organization and Quality Monitors for many clients where our work product is routinely presented to the Office of Inspector General of HHS and the US Department of Justice.

• Provide medical necessity or clinical review services related to litigations between payers and providers or other dispute matters involving medical records, clinical guideline, and medical policy review and interpretation.

• Conduct “mock” Centers for Medicare and Medicaid Services audits by reviewing cases for clinical decision making against CMS and health plan clinical guidelines.

• Assist health plans with obtaining and maintaining NCQA accreditation for utilization management and quality assurance.

• Review services that require prior authorization and the clinical guidelines used to approve or deny cases against widely accepted clinical literature and journal studies.

Position Responsibilities

• Exhibit competency in clinical documentation requirements to meet the following guidelines:

• Medical Necessity – especially as it relates to appropriate level of care and resource management;

• Evaluation and Management and other procedure coding concepts: and

• Diagnosis Coding – especially as it related to Hierarchical Condition Coding (HCC) and ICD-10

• Conduct independent review of medical records

• Drafting of clear and concise analyses of all clinical reviews including those resulting from medical record review

• Review and understanding of payer Utilization Management processes including clinical decision-making protocols

• Knowledge of regulatory and industry guidance related to medical necessity, utilization management, risk adjustment and clinical documentation requirements

• Ability to assess prior authorization and claims denials and experience resolving payer disputes

• Ensures successful completion of high-quality project deliverables as assigned and within the desired timeframe

• Works collaboratively with Ankura team members focusing on building and maintaining internal and external client and counsel relationships

• Proven writing and presentation skills including the ability to prepare reports for expert testimony

• Familiar with accessing and identifying clinical documentation in electronic medical record systems

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Qualifications

• A current, unrestricted license to practice medicine in a US jurisdiction

• Board certification in Internal Medicine or a similar specialty

• Experience in the areas of utilization management, quality improvement, patient safety, and population health

• A working knowledg