Medical Clinical Reviewer, MD/DO

Job not on LinkedIn

🔥 2 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $80 - $145 / hour

⏱ Part Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

👻 Ghost score 0%

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Integrity Management Services, Inc.

WebsiteLinkedInAll Job Openings

51 - 200 employees

💼 Consulting

🏥 Healthcare

🛡️ Insurance

Consulting • Healthcare • Insurance

Integrity Management Services, Inc. is a women-owned, women-run company specializing in helping government and commercial enterprises minimize the risk of improper payments, fraud, waste, and abuse. The company provides a range of services including data analytics, fraud investigations, compliance reviews, audits, grants management, staff augmentation, and coding and medical reviews. IntegrityM, as they are known, works closely with Federal Government agencies, state agencies, and private sector organizations to drive informed decisions and enhance program transparency and oversight. The company is recognized for its contributions to the community and has been awarded for excellence in government contracting and corporate social responsibility.

📋 Description

• Conduct independent clinical reviews of healthcare claims and supporting medical documentation • Review medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and relevant clinical information • Evaluate services for medical necessity, clinical appropriateness, and consistency with accepted standards of medical practice • Assess whether documentation supports billed services, procedures, diagnoses, and level of care • Apply Medicaid policies, coverage requirements, clinical criteria, and review guidelines • Identify potentially unnecessary, excessive, duplicative, unsupported, or questionable services • Develop objective, evidence-based clinical determinations and document review rationales • Respond to clarification or additional clinical-analysis requests • Escalate complex clinical or policy questions and participate in clinical discussions • Maintain consistency, accuracy, and objectivity across assigned reviews • Meet quality, productivity, and project timelines • Maintain confidentiality and security of protected health information and comply with HIPAA and data-security requirements

🎯 Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school • Current, active, and unrestricted license to practice medicine in at least one U.S. state or jurisdiction • Medical license in good standing, with no current restrictions, suspensions, or disciplinary limitations affecting clinical reviews • Minimum of two (2) years of professional clinical experience • Strong knowledge of medical terminology, clinical practice, treatment planning, medical documentation, and generally accepted standards of care • Ability to interpret medical records, diagnostic results, imaging, treatment plans, and other clinical documentation • Strong analytical and critical-thinking skills • Ability to independently evaluate clinical information and develop objective, evidence-based clinical determinations • Ability to clearly and concisely document clinical review findings, conclusions, and supporting rationale • Strong attention to detail and organizational skills • Ability to work independently while meeting quality, productivity, and project timelines in a remote environment • Preferred: board certification or board eligibility in a relevant medical specialty • Preferred: experience in internal medicine, family medicine, psychiatry, or another applicable specialty • Preferred: experience treating Medicaid populations or working with Medicaid programs • Preferred: medical record review, claims review, utilization review, medical necessity review, peer review, payment integrity review, or retrospective clinical review experience • Preferred: familiarity with Medicaid coverage policies, medical necessity requirements, and healthcare program integrity concepts • Preferred: experience evaluating potentially improper, excessive, unsupported, or medically unnecessary healthcare services • Preferred: familiarity with CPT/HCPCS and ICD-10-CM coding and the relationship between clinical documentation and billed services • Preferred: experience supporting health plans, Medicaid agencies, Medicare, government healthcare programs, or healthcare program integrity initiatives

🏖️ Benefits

• U.S. remote annual hourly rate range: $80.00-$145.00 • Flexible workplace • Professional development opportunities • Equal opportunity employment