Medical Director (Medical Policy Ops-DRG)
New
C
CVS HealthHealth Insurance
This is a remote Work at Home position and can be located anywhere in the United States.Full-TimeDirector
Salary$174,070.00 - $374,920.00
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Job Details
- Experience
- Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Requirements
- M.D. or D.O. degree.
- Board Certification in an ABMS recognized specialty.
- Five or more years of experience in health care delivery systems (e.g., clinical practice or health care industry).
- Active and current state medical license without encumbrances.
- Post-graduate direct patient care experience.
- Proficiency in clinical and payment policy, reimbursement, and health care systems.
- Experience with DRG reviews and ICD-10 code selection.
- Knowledge of HCPCS and CPT coding.
- Strong written and verbal communication skills.
Responsibilities
- Provide clinical expertise to support clinical and payment policy.
- Conduct transactional reviews for appeals, clinical claims, and benefit predeterminations.
- Act as a subject matter expert for DRG reviews and ICD-10 code selection.
- Participate in work groups to identify opportunities for improving healthcare service quality and efficiency.
- Apply clinical coding and reimbursement expertise to ensure correct application of company policies.
- Utilize data analysis to identify opportunities for quality improvement.
- Lead and collaborate with diverse health delivery professional teams.
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