Medical Director – Medical Policy Ops, DRG

Role Overview

• Responsible for providing clinical expertise and business direction in support of medical management programs.
• Promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.
• Support the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits.
• Be a subject matter expert in DRG reviews and ICD-10 code selection.
• Proactively use data analysis to identify opportunities for quality improvement.

Requirements

• Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
• Active and current state medical license without encumbrances.
• M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience
• Health plan/payor experience.
• Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.
• Experience with DRG reviews.

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access
• Many other benefits depending on eligibility