Licensed Medical Director
Job Summary
Providing physician-level clinical oversight, the part-time Licensed Medical Director will manage DRG validation, hospital bill audits, and clinical appeals while working remotely to support payer-facing clinical discussions and improve outcomes across clinical services.
Key responsibilities
- Act as a clinical authority and escalation point for the Clinical Services leadership team
- Conduct peer-to-peer reviews of individual claims and analyze appeal outcomes to enhance review guidelines
- Sign off on clinical validation and coding concepts, ensuring thorough review of supporting references
Required qualifications
- Licensed MD with a thorough understanding of APR-DRG and MS-DRG methodology
- Experience in payer/provider appeals and external reviews
- Knowledge of clinical validation and distinctions between coding and clinical criteria
- Familiarity with readmissions logic and inpatient medical necessity
- Client-facing experience with the ability to navigate payer/provider friction
Complete Job Description
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