Medical Director, Payer Clinical Services (US Remote)

Role and Responsibilities:

• Provide clinical interpretation, gray-area guidance, and escalation validation to improve confidence and outcomes across clinical services.
• Perform peer-to-peer review of individual claims and analyze appeal outcomes to make improvements to concepts and review guidelines.
• Sign off on clinical validation and coding concepts, ensuring thorough review of each concept and supporting references.

Qualifications:

• Licensed MD with thorough understanding of APR-DRG and MS-DRG methodology, clinical validation, and coding vs clinical criteria distinctions.
• Experience in payer/provider appeals, external reviews, and client-facing scenarios.
• Ability to navigate payer/provider friction and provide appeals leadership.

Mental and Physical Demands:

• Work in an indoor office environment, sitting most of the time, with continuous typing and use of computer hardware and software.
• Concentrate on analytical tasks, reading information, and verbal/written communication throughout the day.
• Perform related duties as assigned, including compliance requirements such as background screenings and disclosures.