We are seeking a highly experienced DRG Clinical Physician Reviewer to join our growing clinical review team. This is a fully remote opportunity for a physician with a strong background in utilization review and clinical validation who thrives in a fast-paced, data-driven environment.
In this role, you will review complex hospital cases to ensure accurate DRG assignment, validate clinical documentation, and support evidence-based determinations that directly impact healthcare quality and reimbursement integrity.
Responsibilities:
Perform DRG Clinical Validation reviews to ensure diagnoses are accurate, supported, and compliant
Evaluate medical records, diagnostic findings, and treatment plans using evidence-based guidelines
Produce clear, concise clinical summaries and determinations within established turnaround times
Identify opportunities for improved documentation, coding accuracy, and cost containment
Conduct readmission and level of care reviews, including outlier and appeal cases
Collaborate with internal teams and, when needed, engage with providers to support clinical findings
Contribute to quality assurance initiatives and ongoing program development
Qualifications:
MD/DO required with active, unrestricted U.S License