Medical Reviewer, Physician
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Job Description
Physician reviewing claims, authorizations, appeals, and clinical documentation for Gainwell’s California healthcare programs. Applying medical policy and clinical expertise to support accurate determinations.
Responsibilities:
- Perform physician-level medical reviews of claims, Treatment Authorization Requests (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, timeliness, and turnaround-time standards
- Work primarily from a home office supporting California healthcare programs
- Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations
- Travel requirement of 0–10%
Requirements:
- 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
- Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status, as applicable
Benefits:
- Flexible working 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
- Remote work environment
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