DRG Clinical Validation Lead
Core
Ensures medically appropriate, high quality, cost effective care by assessing the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and appropriateness of treatment settings.
Role type
Senior Licensed Nurse (Clinical Validation)
Builds
Medically necessary, quality healthcare access in a cost-effective setting according to contract.
Domain
Healthcare / Managed Care / Clinical Documentation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Acute care clinical experience, Medical necessity assessment, Claims payment interpretation, Managed care policy application, Discharge planning, Regulatory standards application, Team leadership
Preferred skills
RHIT, RHIA, CCDS, CDIP, CPC, CCS, CIC, Third party DRG Coding, Clinical documentation improvement, Provider billing guidelines, Payer reimbursement policies
Technologies
Medical claims billing and payment systems, Coding terminology
Responsibilities
Conduct pre-certification, retrospective, out of network, and appropriateness of treatment setting reviews; Consult with clinical reviewers and medical directors; Collaborate with providers for discharge planning; Facilitate member care transition and refer treatment plans; Ensure consistency in benefit application; Lead cross-functional teams and process improvement activities.
Seniority
Senior, hands-on IC with team lead responsibilities