Medical Director, Payer Clinical Services

This is a fully remote position, open to applicants in United States.

📋 Description

• Deliver physician-level clinical oversight, strategic direction, and escalation support across DRG validation, hospital bill audits, itemized bill reviews, clinical appeals, readmissions/data analysis, and payer-related clinical discussions.

• Serve as a clinical authority, payer relationship resource, escalation contact, and strategic advisor to the Clinical Services leadership team.

• Conduct appeals-related tasks.

• Execute peer-to-peer reviews of individual claims.

• Evaluate appeal outcomes and enhance concepts and review protocols.

• Approve clinical validation concepts and coding standards.

• Conduct thorough examinations of each concept and its supporting references.

• Offer insights for QA reviews as necessary.

• Manage payer/provider conflicts.

• Undertake additional responsibilities as assigned.

• Fulfill compliance requirements set by business partners, which may include background checks, drug screenings, and disclosures of personal health information or personally identifiable information.

⛳️ Requirements

• Must be a licensed MD.

• Comprehensive understanding of APR-DRG and MS-DRG methodologies.

• Familiarity with clinical validation processes.

• Knowledge of distinctions between coding and clinical criteria.

• Insight into readmissions logic.

• Understanding of denial and appeals strategies.

• Awareness of inpatient medical necessity.

• Experience in payer/provider appeals and external review processes.

• Proven leadership experience in appeals.

• Experience in client-facing roles.

• Ability to handle payer/provider conflicts effectively.

• Proficient in using computers and printers.

• Capable of typing and performing repetitive tasks involving computer hardware/software throughout the day.

• Ability to focus on analytical tasks, read information accurately, and communicate effectively both verbally and in writing.

• May be required to meet business-partner compliance standards, including background checks, drug screenings, and disclosures of personal health information or personally identifiable information.

🏝️ Benefits

• Competitive salaries.

• Health insurance.

• 401(k) plan with employer matching contributions.

• Paid parental leave.