Medical Director (Medical Policy Ops-DRG)
Core
Provide clinical expertise to promote high-quality medical care, focusing on clinical and payment policy, DRG reviews, and ICD-10 code selection for commercial and Medicare environments.
Role type
Senior Medical Director (Medical Policy & Operations)
Builds
Clinical and payment policies, appeal decisions, and claim reviews
Domain
US Healthcare / Health Insurance / Medical Policy
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical practice experience, Health care industry knowledge, Medical coding (ICD-10, HCPCS, CPT), Reimbursement expertise, DRG review expertise, Data analysis for quality improvement
Preferred skills
Health plan/payor experience, Clinical policy knowledge, Health care systems knowledge
Responsibilities
Review transactions for appeals and clinical claims, Provide subject matter expertise in clinical and payment policy, Identify opportunities to improve quality and efficiency of health care services, Lead diverse teams of health delivery professionals, Collaborate with functional areas to manage business objectives
Seniority
Senior, hands-on IC with leadership responsibilities
