This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Medical Director/ Physician Reviewer based in the United States.
This role is a clinically focused physician leadership position centered on medical record review, clinical validation, and utilization oversight within a healthcare review environment. You will evaluate hospital records to ensure diagnostic coding accuracy and alignment with established clinical documentation, evidence-based guidelines, and standards of care. The position combines hands-on clinical expertise with analytical review work, producing clear and defensible medical rationales that support determinations. In addition to DRG validation work, you will contribute to readmission reviews, level-of-care assessments, and peer or utilization management activities. This is a detail-oriented, impact-driven role where clinical judgment directly supports quality assurance, appropriate reimbursement, and healthcare system integrity.
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Medical Director/ Physician Reviewer based in the United States.
This role is a clinically focused physician leadership position centered on medical record review, clinical validation, and utilization oversight within a healthcare review environment. You will evaluate hospital records to ensure diagnostic coding accuracy and alignment with established clinical documentation, evidence-based guidelines, and standards of care. The position combines hands-on clinical expertise with analytical review work, producing clear and defensible medical rationales that support determinations. In addition to DRG validation work, you will contribute to readmission reviews, level-of-care assessments, and peer or utilization management activities. This is a detail-oriented, impact-driven role where clinical judgment directly supports quality assurance, appropriate reimbursement, and healthcare system integrity.
Accountabilities:
- Conduct DRG clinical validation reviews by analyzing hospital medical records to assess diagnosis accuracy and coding support within clinical documentation.
- Review cases for readmissions, cost outliers, and appropriate level-of-care determinations based on medical evidence and clinical guidelines.
- Perform utilization management reviews, including initial and appeal-level assessments, as needed.
- Produce clear, concise clinical summaries and well-supported rationales for review findings, aligned with evidence-based medicine and payer or client policies.
- Participate in independent peer review (IRO) activities and other specialized clinical review functions as required.
- Contribute to the development and refinement of clinical review criteria, templates, and standardized language for review processes.
- Support quality assurance initiatives and continuous improvement of clinical review programs.
- Assist in onboarding and training of new physician reviewers when needed.
- MD or DO degree from an accredited medical school with completed postgraduate residency training; fellowship or additional specialization preferred.
- Minimum of 5 years of active clinical practice experience.
- Active, unrestricted medical license in at least one U.S. state, with ongoing eligibility for renewal.
- Board certification from an American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) member board required (or equivalent for DPM as applicable).
- Strong understanding of DRG clinical validation, utilization review, peer review, and evidence-based clinical decision-making.
- Experience in utilization management, medical necessity review, or claims review strongly preferred.
- Ability to evaluate clinical documentation objectively and apply established guidelines and best practices.
- Strong written communication skills with the ability to produce clear, structured medical rationales.
- Excellent analytical and interpretive skills, with the ability to identify clinical trends and issues from medical data.
- Comfortable working independently in a remote, HIPAA-compliant environment with strong attention to confidentiality and detail.
- Annual salary range of 220,000 to 230,000 USD
- Comprehensive medical, dental, and vision insurance coverage for employees and dependents
- 401(k) retirement plan with employer match
- Generous paid time off starting from day one, plus additional sick and holiday leave
- Flexible wellness benefits including FSAs and commuter support options
- Learning and development support, including access to LinkedIn Learning and professional growth resources
- Fully remote work setup with structured requirements for secure and compliant work environments
- Long-term career development in clinical review and healthcare quality assurance
Requirements:
Benefits: