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about 1 month ago
Requirements and responsibilities
Position Summary: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 compliantEvaluate medical records, diagnostic findings, and treatment plans using evidence-based guidelinesProduce clear, concise clinical summaries and determinations within established turnaround timesIdentify opportunities for improved documentation, coding accuracy, and cost containmentConduct readmission and level of care reviews, including outlier and appeal casesCollaborate with internal teams and, when needed, engage with providers to support clinical findingsContribute to quality assurance initiatives and ongoing program developmentQualifications:MD/DO required with active, unrestricted U.S LicenseBoard Certification required (ABMS or AOA)5+ years of clinical practice experienceREQUIRED: Strong utilization review experience (UM, DRG Validation, or clinical documentation review)Experience with DRG Validation, CDI, or claims review strongly preferredProven ability to interpret complex clinical data and apply guidelines objectivelyStrong written communication skills with the ability to clearly justify clinical decisionsWhy This Role Stands Out:100% remote – work from anywhere in the U.SHigh-impact role influencing clinical accuracy and healthcare outcomesJoin a growing, mission-driven team at the intersection of clinical care and healthcare analyticsConsistent, structured workflow with meaningful case variety
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