This Medical Director provides physician-level oversight for payment integrity and appeals work, focusing on DRG validation, hospital bill audits, itemized bill review, readmissions, and payer-facing clinical discussions. The role centers on clinical interpretation of claims and medical necessity questions, with escalation support for gray-area cases and peer-to-peer review. It is a remote, non-clinical practice role that relies on collaboration with clinical services leadership, payers, and providers in a tech-enabled workflow.
Key Responsibilities
- Provide clinical oversight and escalation support for DRG validation, bill audits, itemized bill review, appeals, and readmissions analysis.
- Conduct peer-to-peer review of individual claims and support payer-facing clinical discussions.
- Review appeal outcomes and help refine review guidelines and clinical validation concepts.
- Sign off on clinical validation concepts and coding concepts after reviewing supporting references.
- Provide guidance on coding versus clinical criteria distinctions and inpatient medical necessity questions.
- Participate in quality assurance reviews as needed.
- Coordinate with Clinical Services leadership as a clinical authority and strategic advisor.
Required
- Licensed MD.
- Experience with APR-DRG and MS-DRG methodology.
- Understanding of clinical validation and coding versus clinical criteria distinctions.
- Knowledge of readmissions logic, denials, and appeals strategy.
- Experience with inpatient medical necessity reviews.
- Experience in payer or provider appeals and external reviews.
Preferred
- Client-facing experience.
- Experience navigating payer and provider friction.
Benefits & Perks
- Remote work.
- Competitive salary.
- Health insurance.
- 401(k) with employer match.
- Paid parental leave.