The Clinical Review Medical Director is primarily responsible for reviewing hospital medical records submitted for DRG Clinical Validation Review to ensure select diagnoses were billed appropriately and are supported in the medical record. The Medical Director will produce a concise summary of the clinical course, including diagnostic studies and other relevant data, and compose a rationale consistent with guidelines, literature, client policy, and standard of care for any adverse finding. The Medical Director, from time to time, will also review cases to identify potentially preventable near-term readmission, identify appropriate inpatient Level of Care, and assist with Independent Peer Review, and Utilization Management.
Specific Duties:
This list does not represent all responsibilities for this position.
Review Activities:
- DRG Clinical Validation
- Readmission Review
- Cost Outlier Level of Care review
- IRO review activity, as required.
- UM review activity, Initial and Appeal Level, as required.
Participate, from time to time, in the following activities:
- Develop and update DRG Clinical Validation Review criteria.
- Develop and update model language for review activity.
- Quality assurance activities related to clinical review programs.
- Training/on-boarding of new Medical Directors.
Requirements:
- Education: MD/DO degree from an accredited medical school with relevant postgraduate residency or fellowship training. Additional education in health policy and/or management preferred.
- Experience: Five or more years of full time equivalent clinical practice experience is mandatory. Utilization management, DRG review, peer review, and claim review experience is desirable.
- Active, valid, and non-restricted licensure to practice medicine or a health profession in at least one state of the United States and documentation of re-licensure at the time of the renewal period.
- Physician reviewers must possess and submit documentation of current Board certification by a member Board of the American Board of Medical Specialties (M.D.) or by a member Board of the American Osteopathic Association (D.O.) or in the case of a D.P.M. by the American Board of Podiatric Surgery, respectively.
- Must be located within a US state territory at the time of performing any review.
Competencies:
- Understanding of the principles of DRG clinical validation review, utilization review, evidence-based medicine and the healthcare and health insurance industry in general.
- Ability to objectively evaluate, assess, and weigh alternative plans of care and therapy treatment using best medical evidence and/or relevant practice or clinical guidelines.
- Ability to produce necessary determinations within specified time limits.
- Solid quantitative and analytical skills.
- Ability to engage, if needed, with clients, hospitals, physicians, and other professionals in a collegial manner.
- Ability to convey the essence of clinical issues to non-physician staff if needed.
- Strong written communication skills
- Ability to interpret data to identify trends and medical issues.
- Ability to use computers and other office equipment necessary to perform assigned tasks.
- Ability to learn and use computer applications/programs necessary to perform assigned tasks.
Remote Work Requirements:
- High speed internet (100 Mbps per person recommended) with secured WIFI.
- A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
- Must be able to sit and use a computer keyboard for extended periods of time.
Benefits and perks include:
- Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
- 401(k) with Employer Match - Join the team and we will invest in your future
- Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays.
- Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered.
- Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.
Salary Range: $220,000- 230,000/ annually.
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