Medical Director – Medical Policy Ops, DRG

Job Description: • 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 Apply Now Apply Now