Medical Reviewer (Physician) - Remote CA

Gainwell Technologies LLC•West Sacramento, CA

1d•$140,000 - $160,000•Remote

About The Position

Gainwell 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. The position is full-time and remote, with a Monday through Friday work schedule. The majority of the day will be spent reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to the area of expertise. The role requires navigating multiple computer systems and applications to complete reviews, document findings, and support timely determinations. Ongoing training and support related to program requirements, systems, policies, and medical review processes will be provided.

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.
Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, and regulatory guidelines.
Meet established quality, accuracy, productivity, and turnaround-time expectations.

Responsibilities

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.