Medical Director (Medical Policy Ops-DRG)
$174,070–$374,920 year
RemoteUnited States
Job Summary
Conduct transactional reviews for the appeal process, clinical claim review, and predetermination of covered benefits across Commercial and Medicare environments. Serve as a subject matter expert in DRG reviews, ICD-10 code selection, and clinical coding policy to ensure alignment with Aetna reimbursement practices. Lead diverse teams of health delivery professionals, collaborate with functional areas, and proactively use data analysis to identify quality improvement opportunities. Provide clinical expertise to promote high-quality, constituent-focused medical care while managing business objectives within the Medical Policy & Operations function.
Required Qualifications
- 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
- willingness to learn
Desired Qualifications
- 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.
- Strong communication skills both written and verbal.
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