Senior Physician Reviewer

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $240k - $250k / year

⏰ Full Time

🟠 Senior

👻 Ghost score 2%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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MedReview Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

⚕️ Healthcare Insurance

💸 Finance

Healthcare • Healthcare Insurance • Finance

MedReview Inc. is a leading provider of advanced payment integrity solutions, specializing in healthcare claims. They work with a wide range of clients, including health plans, government agencies, and payors, to reduce unnecessary waste and save billions of dollars. Their team of highly trained physicians, registered nurses, and certified coders conduct thorough clinical and coding reviews to identify inaccuracies in healthcare claims. MedReview employs proprietary algorithms to analyze complex data and detect suspicious payment trends, offering a unique blend of clinical expertise and advanced technology to maximize efficiencies and improve healthcare cost management.

📋 Description

• Perform complex clinical validation reviews and provide final physician determinations on disputed findings • Review and validate diagnoses, severity of illness, risk adjustment factors, clinical documentation, medical necessity, and reimbursement-related issues • Conduct DRG validation and clinical documentation reviews • Perform readmission reviews assessing preventability, appropriateness, and documentation support • Review escalated, high-dollar, high-risk, and clinically complex cases • Provide specialty-specific clinical expertise for inpatient and outpatient payment integrity reviews • Manage physician-level appeals involving clinical validation, DRG validation, medical necessity, and other payment integrity findings • Conduct peer-to-peer discussions with treating physicians and hospital representatives • Prepare and review evidence-based clinical rationale letters • Participate in external review processes with providers, health plans, clients, and regulatory agencies • Respond to Medicare complaints, regulatory inquiries, Independent Review Organization requests, and escalated appeals • Provide clinical support during litigation, arbitration, audits, and formal dispute resolution • Ensure reviews comply with CMS regulations, Medicare guidelines, state requirements, payer policies, clinical criteria, and industry standards • Support quality assurance, reviewer calibration, internal audits, client audits, audit-of-audit programs, and continuous quality improvement • Develop and maintain clinical review policies, methodologies, decision frameworks, and documentation standards • Monitor appeal overturn trends, identify root causes, and recommend improvements • Lead, coach, mentor, and provide clinical oversight to physician reviewers, nurse reviewers, clinical validation specialists, and appeals staff • Assist with hiring, onboarding, training, calibration, performance development, workforce planning, productivity monitoring, and quality management • Serve as a clinical consultant to Operations, Account Management, Client Services, Implementation, Quality, Compliance, and executive leadership • Participate in client meetings, operational reviews, and business development activities • Present clinical findings, trends, and recommendations to clients and executive stakeholders • Support implementation of payment integrity programs and client requirements • Assist with methodology development, scope expansion, and new program opportunities • Collaborate with coding, analytics, quality, compliance, operations, and technology teams to improve accuracy, efficiency, and outcomes • Deliver physician determinations within turnaround times and service-level requirements • Maintain physician reviewer quality scores of 95% or greater • Strengthen appeal defense, improve decision consistency, and reduce avoidable overturns • Build reviewer capability through coaching, training, and clinical oversight • Contribute to client satisfaction, program expansion, and MedReview growth initiatives

🎯 Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school • Active, unrestricted physician license in at least one U.S. state • Current board certification in an applicable medical specialty • Ability to obtain additional state licenses as business or client needs require • 10+ years of clinical practice experience • 5+ years of experience in payment integrity, utilization management, revenue cycle, health plan operations, auditing, or healthcare review • Physician-level review experience in clinical validation, DRG validation, readmission and medical necessity reviews, coding-related clinical reviews, appeals and reconsiderations, peer-to-peer discussions, and Medicare/regulatory complaint resolution • Experience supporting Commercial, Medicare Advantage, Medicaid, and other government healthcare programs • Prior leadership or supervisory experience supporting physician, nursing, clinical review, or healthcare operations teams • Expert knowledge of Clinical Documentation Improvement (CDI), clinical validation and DRG validation, Medicare rules, CMS requirements, payer policies, payment integrity methodologies, Revenue Cycle Management, medical necessity criteria, appeals, grievances, and regulatory complaint processes • Strong understanding of healthcare reimbursement methodologies and payer-provider payment processes • Excellent written and verbal communication skills • Exceptional provider-relations and peer-to-peer communication skills • Strong analytical, critical-thinking, and problem-solving capabilities • Ability to lead and influence cross-functional clinical and operational teams • Multi-state physician licensure preferred • Experience as a Medical Director, Associate Medical Director, Senior Medical Director, or Senior Physician Advisor preferred • Experience with RAC, UPIC, Medicaid Program Integrity, Medicare Advantage, or payment integrity vendors preferred • Certification or advanced training in healthcare quality, utilization management, risk adjustment, patient safety, or healthcare compliance preferred • Experience with CMS, Medicare Advantage plans, Medicaid programs, commercial health plans, third-party administrators, or provider appeals organizations preferred • Legally authorized to work in the United States without employer-sponsored visa assistance, now or in the future

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