SummaryGainwell Technologies is seeking a
Medical Reviewer (Physician) to support Medical Review Services for California healthcare programs. This role provides physician-level clinical expertise supporting medical policy, claim adjudication, Treatment Authorization Requests (TARs), appeals, provider-related medical review activities, and other healthcare program requirements.
Your role in our mission- Perform physician-level medical reviews of claims, 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, and timeliness standards.
What we're looking for- 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.
What you should expect in this role- Full-time position.
- Remote work environment.
- Monday through Friday work schedule.
- Work primarily from your home office while supporting Medical Review Services for California healthcare programs.
- Spend the majority of your day reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to your area of expertise.
- Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners.
- Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
- Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status, as applicable.
- Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, and regulatory guidelines.
- Meet established quality, accuracy, productivity, and turnaround-time expectations.
- Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.
- Travel requirement: 0-10%.
This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.#LI-REMOTE
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The pay range for this position is $140,000 - $160,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
