A physician leader and clinical subject matter expert serving as a lead for complex payment integrity reviews, clinical validation determinations, DRG validation, readmission reviews, appeals, peer-to-peer discussions, and regulatory complaint resolution.
Compensation - $240,000 - $250,000
- Perform complex clinical validation reviews and provide final physician determinations on disputed findings.
- Review and validate diagnoses, severity of illness, risk adjustment factors, clinical documentation, medical necessity, and reimbursement-related issues.
- Conduct DRG validation and clinical documentation reviews to confirm accurate assignment and reimbursement.
- Perform readmission reviews, including assessments of preventability, appropriateness, and documentation support.
- Review escalated, high-dollar, high-risk, and clinically complex cases requiring physician-level judgment.
- Doctor of Medicine (MD)
- Doctor of Osteopathic Medicine (DO)
- Nice to have: Multi-state physician licensure
- Nice to have: Experience as Medical Director
- Nice to have: Experience with RAC, UPIC, or Medicaid Program Integrity
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