Medical Reviewer – Prosthetic and Orthotic Devices Specialist
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Medical Reviewer evaluating prosthetic and orthotic device claims for Gainwell’s California healthcare programs. Reviewing medical necessity, coverage, authorizations, and supporting documentation.
Responsibilities:
- Review claims, Treatment Authorization Requests (TARs), prescriptions, and supporting documentation involving prosthetic and orthotic devices
- Evaluate prosthetic and orthotic requests based on applicable coverage requirements, medical policies, and professional standards
- Assess documentation supporting the medical need and appropriate use of prosthetic and orthotic devices
- Provide subject-matter expertise related to prosthetic and orthotic equipment, services, and practices
- Support claim adjudication and authorization activities involving prosthetic and orthotic services
- Document review findings, decisions, and supporting rationale accurately and timely
- Identify documentation or coverage issues requiring additional review or clarification
- Collaborate with clinicians, providers, operations teams, and other Medical Review Services specialists
- Maintain knowledge of applicable prosthetic and orthotic standards, coverage requirements, policies, and regulatory guidelines
- Meet established quality, accuracy, productivity, and turnaround-time expectations
- Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations
Requirements:
- Professional experience as a Prosthetic and Orthotic (P&O) practitioner consistent with program requirements
- Certification in Prosthetics and Orthotics
- Ownership or management of a Prosthetic and Orthotic business within the past five (5) years preferred
- Strong knowledge of prosthetic and orthotic devices, services, and clinical applications
- Ability to interpret medical documentation, prescriptions, and supporting device information
- 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
- 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
Similar Jobs
Medical Reviewer, Laboratory Specialist
Medical laboratory reviewer supporting Gainwell’s California healthcare programs. Reviewing claims, authorizations, and documentation for coverage, medical necessity, and compliance.
Medical Reviewer – Durable Medical Equipment Specialist
Medical Reviewer evaluating DME claims, authorizations, and documentation for Gainwell’s California healthcare programs. Ensuring medical necessity, coverage, billing, and program compliance.
Medical Reviewer – Speech and Audiology Specialist
Medical Reviewer applying speech, language, and audiology expertise to California healthcare claims and authorizations. Supporting medical necessity decisions for Gainwell Technologies’ healthcare programs.
Medical Reviewer, Radiologist
Radiologist reviewing California radiology claims, medical records, and authorization requests for Gainwell Technologies. Supporting medical necessity determinations for healthcare programs.
Medical Reviewer, Podiatrist
Podiatrist reviewing medical records, claims, and treatment authorizations for Gainwell Technologies’ California healthcare programs. Applying clinical judgment to medical necessity and coverage decisions.
Medical Reviewer, Registered Nurse
Medical Reviewer (Registered Nurse) reviewing California healthcare records, claims, and authorizations for Gainwell Technologies. Determining medical necessity and supporting healthcare program compliance remotely.
Medical Reviewer – Physical Therapist
Medical Reviewer evaluating physical therapy records, claims, and authorizations for Gainwell Technologies’ California healthcare programs. Supporting clinical necessity and coverage determinations remotely.
Medical Reviewer, Optometrist
Medical Reviewer applying optometric expertise to California healthcare claims, records, and authorizations. Supporting medical necessity determinations for Gainwell Technologies’ healthcare programs.
Medical Reviewer, Pharmacist
Medical Reviewer (Pharmacist) supporting Gainwell Technologies’ California healthcare programs. Reviewing pharmacy claims, drug authorizations, utilization, rebates, and clinical documentation remotely.
Medical Reviewer, Physician
Physician reviewing claims, authorizations, appeals, and clinical documentation for Gainwell’s California healthcare programs. Applying medical policy and clinical expertise to support accurate determinations.
Medical Reviewer – Medicare, Home Health
Registered Nurse reviewing complex Medicare home-health claims, authorizations, appeals, and fraud referrals. Applying clinical guidelines to determine medical necessity and support accurate payment decisions.
Clinical Reviewer – PT, OT Licensed
Clinical Reviewer evaluating workers’ compensation therapy authorizations for nonprofit Comagine Health. Applying clinical criteria, documenting medical necessity decisions, and preparing reports and denial recommendations.
Medical Clinical Reviewer, Clinical Program Specialist – Managing Consultant
Clinical reviewer supporting Guidehouse’s federal healthcare programs. Evaluating medical necessity, documentation, care pathways, and operational decisions across complex healthcare environments.
Pediatric Rheumatology – Independent Medical Reviewer
Board-certified pediatric rheumatology physician conducting objective chart reviews for MMRO, a URAC-accredited medical review organization. Producing evidence-based determinations that support healthcare decisions.
Pediatric Nephrologist – Independent Medical Reviewer
Board-certified pediatric nephrologist conducting objective, evidence-based medical chart reviews for MMRO. Producing clear determinations remotely as an independent contracted physician reviewer.
Clinical Data Reviewer
Clinical Data Reviewer monitoring clinical-trial data for global medical research company. Identifying data issues, supporting risk-based monitoring, and improving study-data quality.
Medical Reviewer, Senior Medical Reviewer
Medical Reviewer ensuring AbbVie promotional and non-promotional materials comply with UK pharmaceutical codes. Supporting brand teams, product launches, medical reviews, and compliant marketing campaigns.
Clinical Data Reviewer – Oncology
Clinical Data Reviewer specializing in Oncology at Syneos Health. Ensuring data readiness and conducting clinical reviews for oncology studies.
RN Medical Reviewer II
RN Medical Reviewer II performing claims reviews for medically complex services. Supporting healthcare administration for BlueCross BlueShield's subsidiary companies while working remotely.
Reviewer II, Medical
Reviewer II, Medical performing medical reviews for claims in a remote role with BlueCross BlueShield. Requires nursing licensure and clinical experience for this full-time position.