Medical Director/ Physician Reviewer

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.

• 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