Medical Reviewer (Laboratory Specialist) - Remote

Summary

Gainwell Technologies is seeking a Medical Reviewer (Laboratory Specialist) to provide laboratory subject-matter expertise supporting Medical Review Services for California healthcare programs. In this role, you will review laboratory-related claims, Treatment Authorization Requests (TARs), orders, and supporting documentation to help ensure laboratory services meet applicable coverage, medical necessity, and program requirements.

Your role in our mission

• Review laboratory-related claims, Treatment Authorization Requests (TARs), orders, and supporting documentation.
• Evaluate laboratory services based on applicable medical policies, coverage requirements, and program guidelines.
• Apply laboratory expertise when reviewing the appropriateness of requested or billed laboratory services.
• Support claim adjudication and medical review activities involving laboratory testing.
• Review supporting documentation for completeness and alignment with applicable program requirements.
• Document review findings, decisions, and supporting rationale accurately and timely.
• Identify documentation, billing, or coverage issues requiring additional review or clarification.
• Collaborate with clinical, operational, provider-facing, and other Medical Review Services teams to resolve laboratory review questions.
• Maintain knowledge of applicable laboratory practices, medical policies, coverage requirements, and healthcare program guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.

What we're looking for

• Minimum of two (2) years of experience as a laboratory technician.
• High school diploma or equivalent.
• Completion of a Medical Laboratory Technician program from an accredited medical laboratory technician school.
• Knowledge of laboratory procedures, terminology, testing, and documentation.
• Ability to interpret laboratory-related records, orders, claims, and supporting documentation.
• Strong analytical, written, and verbal communication skills.
• Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams.

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 laboratory-related claims, authorization requests, orders, medical documentation, and supporting records.
• Work independently while collaborating with physicians, nurses, other clinical specialists, operations teams, providers, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain all professional certifications and credentials required for the position in active and good-standing status, as applicable.
• Maintain knowledge of applicable medical policies, laboratory practices, coverage requirements, 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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