Medical Reviewer – Laboratory Specialist
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Job Description
Medical Reviewer evaluating laboratory claims, authorizations, and documentation for Gainwell Technologies’ California healthcare programs. Applying laboratory expertise to support accurate medical necessity and coverage determinations.
Responsibilities:
- 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 to review the appropriateness of requested or billed laboratory services
- Support claim adjudication and medical review activities involving laboratory testing
- Review documentation for completeness and alignment with 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 Medical Review Services teams
- Maintain knowledge of laboratory practices, medical policies, coverage requirements, and healthcare program guidelines
- Meet established quality, accuracy, productivity, and turnaround-time expectations
- Navigate multiple computer systems and applications to complete reviews and document findings
- Support timely determinations for California healthcare programs
Requirements:
- 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
- Maintain all professional certifications and credentials required for the position in active and good-standing status, as applicable
Benefits:
- Flexible hours
- Work-life balance
- Continuous learning and career development
- Remote work environment
- Flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
- Ongoing training and support
- 0–10% travel requirement
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