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.
Requirements:
- 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.
Benefits:
- 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
How Jobgether works:
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
Why Apply Through Jobgether?
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