Medical Director, DRG Audit & AI Innovation

MD/DO with active, unrestricted license. Board certification in Internal Medicine, Surgery, Family Medicine, or related specialty with inpatient care experience. 3+ years of experience performing DRG audits, utilization management, or clinical validation reviews. Deep familiarity with ICD-10-CM/PCS, AHA Coding Clinic guidance, and CMS DRG policies. Experience working with AI-powered or technology-enabled audit platforms (preferred). Demonstrated ability to translate clinical reasoning into structured or algorithmic formats (preferred). Strong written communication skills. Comfort working in cross-functional teams.

Conduct DRG reviews to validate diagnoses, procedures, and coding. Apply industry standard guidelines, coding rules, and organizational policies. Deliver clear, well-documented rationale for determinations. Translate case-based reasoning into structured feedback for the AI adjudicator. Flag nuanced cases and conflicting data to inform AI handling of uncertainty. Collaborate with teams to refine policy JSONs, decision trees, and narrative outputs. Identify opportunities to capture clinical nuance for AI accuracy. Serve as a subject matter expert for coding teams, nurses, and data scientists. Provide input on audit guidelines, clinical validation criteria, and education materials. Participate in quality improvement initiatives.