Medical Reviewer, Physician

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🏄 California – Remote

🏄 California – Remote

💵 $140k - $160k / year

⏰ Full Time

🟢 Junior

🔍🏥 Medical Reviewer

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• 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