Medical Reviewer (Optometrist) - Remote CA

Gainwell Technologies LLC•West Sacramento, CA

1d•$100,000 - $120,000•Remote

About The Position

Gainwell Technologies is seeking a Medical Reviewer (Optometrist) to provide professional optometric expertise supporting Medical Review Services for California healthcare programs. This role involves reviewing optometry-related medical records, claims, Treatment Authorization Requests (TARs), and supporting clinical documentation. The reviewer will evaluate requested services against applicable medical policies, coverage requirements, and clinical standards, applying professional optometric expertise to support medical necessity and coverage determinations. Key responsibilities include documenting findings and clinical rationale accurately and timely, referring cases requiring additional clinical review to appropriate medical professionals, collaborating with clinical and operational partners to resolve review questions, and maintaining knowledge of applicable policies and regulatory requirements. The position requires meeting established quality, accuracy, productivity, and turnaround-time standards.

Requirements

Minimum of one (1) year of experience working as an Optometrist.
Doctor of Optometry degree from an accredited school of Optometry.
Current, non-expired California license to practice as an Optometrist, in good standing.
Must not be under suspension from Medicare, Medicaid, or practice in California.
Must not have been previously sanctioned for fraud or abuse.
Strong oral and written communication skills.
Strong clinical judgment and ability to interpret medical records and supporting clinical documentation.

Responsibilities

Review optometry-related medical records, claims, Treatment Authorization Requests (TARs), and supporting clinical documentation.
Evaluate requested services against applicable medical policies, coverage requirements, and clinical standards.
Apply professional optometric expertise when supporting medical necessity and coverage determinations.
Document findings and clinical rationale accurately and timely.
Refer cases requiring additional clinical review to appropriate medical professionals.
Collaborate with clinical and operational partners to resolve review questions.
Maintain knowledge of applicable policies and regulatory requirements.
Meet established quality, accuracy, productivity, and turnaround-time standards.
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.
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.