Job Description
Position Summary The Clinical Review Medical Director is primarily responsible for reviewing hospital medical records submitted for DRG Clinical Validation Review to ensure select diagnoses were billed appropriately and are supported in the medical record. The Medical Director will produce a concise summary of the clinical course, including diagnostic studies and other relevant data, and compose a rationale consistent with guidelines, literature, client policy, and standard of care for any adverse finding. The Medical Director, from time to time, will also review cases to identify potentially preventable near-term readmission, identify appropriate inpatient Level of Care, and assist with Independent Peer Review, and Utilization Management. Specific Duties: This list does not represent all responsibilities for this position. Review Activities: DRG Clinical Validation Readmission Review Cost Outlier Level of Care review IRO review activity, as required. UM review activity, Initial and Appeal Level, as required. Participate, from time to time, in the following activities: Develop and update DRG Clinical Validation Review criteria. Develop and update model language for review activity. Quality assurance activities related to clinical review programs. Training/on-boarding of new Medical Directors. Requirements: Education: MD/DO degree from an accredited medical school with relevant postgraduate residency or fellowship training. Additional education in health policy and/or management preferred. Experience: Five or more years of full time equivalent clinical practice experience is mandatory. Utilization management, DRG review, peer review, and claim review experience is desirable. Active, valid, and non-restricted licensure to practice medicine or a health profession in at least one state of the United States and documentation of re-licensure at the time of the renewal period. Physician reviewers must possess and submit documentation of current Board certification by a mem
