Medical Reviewer (Physician) - Remote CA

Summary

Gainwell Technologies is seeking a Medical Reviewer (Physician) to support Medical Review Services for California healthcare programs. This role provides physician-level clinical expertise supporting medical policy, claim adjudication, Treatment Authorization Requests (TARs), appeals, provider-related medical review activities, and other healthcare program requirements.

Your role in our mission

• Perform physician-level medical reviews of claims, TARs, appeals, and other clinical documentation.
• Apply medical expertise, applicable policies, coverage requirements, and clinical standards when making or supporting review determinations.
• Provide technical and clinical expertise related to suspended claims, appeals, provider inquiries, and other medical review activities.
• Support medical policy interpretation and development as needed.
• Provide clinical expertise supporting drug utilization review when assigned.
• Document medical review findings and clinical rationale clearly and accurately.
• Collaborate with pharmacists, nurses, other clinicians, operations teams, and business partners.
• Maintain knowledge of applicable Medicaid, Medicare, California healthcare program, and regulatory requirements.
• Meet established quality, accuracy, productivity, and timeliness standards.

What we're looking for

• Current, non-expired physician license from the State of California, in good standing.
• 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.
• Three (3) years of experience as a medical consultant for a government or private-sector healthcare payer; or one (1) year of MMIS experience providing technical expertise and assistance for the entire suspended claims process, appeals process, and provider relations; or three (3) years of experience in drug utilization review.
• Strong oral and written communication skills.
• Strong clinical judgment and ability to interpret complex medical documentation.

What you should expect in this role

• Full-time position.
• Remote work environment.
• Monday through Friday work schedule.
• Work primarily from your home office while supporting Medical Review Services for California healthcare programs.
• Spend the majority of your day reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to your area of expertise.
• Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status, as applicable.
• Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, and regulatory guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.
• Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.
• Travel requirement: 0-10%.

This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.

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