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 compliant
• Evaluate medical records, diagnostic findings, and treatment plans using evidence-based guidelines
• Produce clear, concise clinical summaries and determinations within established turnaround times
• Identify opportunities for improved documentation, coding accuracy, and cost containment
• Conduct readmission and level of care reviews, including outlier and appeal cases
• Collaborate with internal teams and, when needed, engage with providers to support clinical findings
• Contribute to quality assurance initiatives and ongoing program development
Qualifications:
• MD/DO required with active, unrestricted U.S License
• Board Certification required (ABMS or AOA)
• 5+ years of clinical practice experience
• REQUIRED: Strong utilization review experience (UM, DRG Validation, or clinical documentation review)
• Experience with DRG Validation, CDI, or claims review strongly preferred
• Proven ability to interpret complex clinical data and apply guidelines objectively
• Strong written communication skills with the ability to clearly justify clinical decisions
Why This Role Stands Out:
• 100% remote – work from anywhere in the U.S
• High-impact role influencing clinical accuracy and healthcare outcomes
• Join a growing, mission-driven team at the intersection of clinical care and healthcare analytics
• Consistent, structured workflow with meaningful case variety
Compensation: 230K