Medical Reviewer, Optometrist
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Job Description
Medical Reviewer applying optometric expertise to California healthcare claims, records, and authorizations. Supporting medical necessity determinations for Gainwell Technologies’ healthcare programs.
Responsibilities:
- Review optometry-related medical records, claims, Treatment Authorization Requests (TARs), and supporting clinical documentation
- Evaluate requested services against applicable medical policies, coverage requirements, and clinical standards
- Apply professional optometric expertise to support medical necessity and coverage determinations
- Document findings and clinical rationale accurately and timely
- Refer cases requiring additional clinical review to appropriate medical professionals
- Collaborate with clinical and operational partners to resolve review questions
- Maintain knowledge of applicable policies and regulatory requirements
- Meet established quality, accuracy, productivity, and turnaround-time standards
- Work primarily from a home office supporting Medical Review Services for California healthcare programs
- Work independently while collaborating with physicians, nurses, clinical specialists, operations teams, and business partners
- Navigate multiple computer systems and applications to complete reviews and document findings
Requirements:
- Minimum of one (1) year of experience working as an Optometrist
- Doctor of Optometry degree from an accredited school of Optometry
- Current, non-expired California license to practice as an Optometrist, in good standing
- Must not be under suspension from Medicare, Medicaid, or practice in California
- Must not have been previously sanctioned for fraud or abuse
- Strong oral and written communication skills
- Strong clinical judgment and ability to interpret medical records and supporting clinical documentation
- Ability to maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status
- Travel requirement: 0-10%
Benefits:
- Flexible hours
- Work-life balance
- Continuous learning and career development
- Flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
- Ongoing training and support
- Remote work environment
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