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 treatment settings.
Role type
Senior IC clinical validation lead (nursing background)
Builds
Medical necessity determinations for inpatient/outpatient services and claims payment accuracy
Domain
US Healthcare / Managed Care / DRG Clinical Validation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Acute care clinical experience, Medical necessity assessment, Contract interpretation, Appeals management, Discharge planning, Regulatory standards application, Team leadership, Cross-functional collaboration
Preferred skills
RHIT, RHIA, CCDS, CDIP, CPC, CCS, CIC, Third-party DRG coding, Clinical documentation improvement, Managed care experience, Lead experience
Technologies
Medical claims billing and payment systems, Provider billing guidelines, Payer reimbursement policies, 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 transitions; Ensure consistency in benefit application; Lead cross-functional teams and process improvement activities.
Seniority
Senior, hands-on IC with team lead responsibilities