Medical Reviewer – Durable Medical Equipment Specialist
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Job Description
Medical Reviewer evaluating DME claims, authorizations, and documentation for Gainwell’s California healthcare programs. Ensuring medical necessity, coverage, billing, and program compliance.
Responsibilities:
- Review DME-related claims, Treatment Authorization Requests (TARs), prescriptions, and supporting medical documentation
- Evaluate durable medical equipment requests against medical policies, coverage requirements, and program guidelines
- Review documentation supporting medical necessity and appropriate DME use
- Apply knowledge of DME products, supplies, billing practices, and healthcare reimbursement
- Support claim adjudication and authorization activities involving DME
- Document review findings, decisions, and supporting rationale accurately and timely
- Identify documentation, billing, or coverage issues requiring additional review or clarification
- Collaborate with clinicians, providers, operations teams, and Medical Review Services professionals
- Maintain knowledge of DME policies, coverage requirements, billing practices, and regulatory guidelines
- Meet established quality, accuracy, productivity, and turnaround-time expectations
Requirements:
- Minimum of three (3) years of professional experience working with Durable Medical Equipment (DME)
- Strong knowledge of DME products, equipment, supplies, and their uses
- Management of a DME business and/or understanding of healthcare billing preferred
- Ability to interpret medical documentation, prescriptions, claims, and supporting information
- Strong analytical, documentation, written, and verbal communication skills
- Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams
- Must work from a home office while supporting California healthcare programs
- Ability to navigate multiple computer systems and applications
Benefits:
- Flexible hours
- Work-life balance
- Continuous learning and career development
- Generous, flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
- Ongoing training and support related to program requirements, systems, policies, and medical review processes
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