Medical Director (Medical Policy Ops-DRG)
Core
Provide clinical expertise to promote high-quality medical care with a focus on clinical and payment policy, including transactional reviews for appeals, claim reviews, and predetermination of covered benefits.
Role type
Senior Medical Director (Medical Policy & Operations)
Builds
Clinical and payment policies for Commercial and Medicare environments
Domain
US Health Insurance / Medical Policy
Required skills
Clinical expertise, Medical coding (ICD-10, HCPCS, CPT), DRG reviews, Policy analysis, Data analysis, Team leadership
Preferred skills
Health plan/payor experience, Reimbursement expertise, Health care systems knowledge
Responsibilities
Review clinical claims and appeals, Determine covered benefits, Provide subject matter expertise in DRG reviews and coding, Lead diverse health delivery teams, Collaborate with functional areas to improve care quality and efficiency
Seniority
Senior, hands-on IC
