Medical Reviewer (Physician)
G
Gainwell TechnologiesHealthcare
United StatesFull-TimeMiddle
Salary140,000 - 160,000 USD per year
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Job Details
- Experience
- 3 years of experience as a medical consultant for a government or private-sector healthcare payer; or 1 year of MMIS experience; or 3 years of experience in drug utilization review.
Requirements
- Current, non-expired physician license from the State of California in good standing.
- Three years of experience as a medical consultant for a government or private-sector healthcare payer.
- Alternative: One year of MMIS experience providing technical expertise for suspended claims, appeals, and provider relations.
- Alternative: Three years of experience in drug utilization review.
- Strong clinical judgment and ability to interpret complex medical documentation.
- Strong oral and written communication skills.
- Ability to navigate multiple computer systems to document findings.
- Must not be under suspension from Medicare, Medicaid, or the practice of medicine in California.
- Must not have been previously sanctioned for fraud or abuse.
Responsibilities
- Perform physician-level medical reviews of claims, Treatment Authorization Requests (TARs), appeals, and clinical documentation.
- Apply medical expertise, policies, coverage requirements, and clinical standards to review determinations.
- Provide technical and clinical expertise for suspended claims, provider inquiries, and medical review activities.
- Support medical policy interpretation and development.
- Provide clinical expertise for drug utilization review when assigned.
- Document medical review findings and clinical rationale accurately.
- Collaborate with pharmacists, nurses, clinicians, and business partners.
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