Senior Physician Reviewer

MedReview•, (Multiple States)

5d•$240,000 - $250,000

About The Position

MedReview is a provider of payment integrity solutions serving health plans, third-party administrators, and other healthcare organizations. The Senior Physician Reviewer reports to the Senior Medical Director and serves as a physician leader and clinical subject matter expert for complex payment integrity reviews, clinical validation determinations, DRG validation, readmission reviews, appeals, peer-to-peer discussions, and regulatory complaint resolution. The role provides physician-level judgment on disputed, high-dollar, high-risk, and clinically complex matters, and serves as a supervisory and consultative resource to physician reviewers, nurse auditors, coders, quality teams, operations, and client-facing leaders. The Senior Physician Reviewer applies clinical expertise, regulatory knowledge, and payment integrity experience to deliver accurate, defensible, and compliant determinations across Commercial, Medicare Advantage, Medicaid, and other government-sponsored healthcare programs. The role supports clinical quality, provider credibility, client satisfaction, regulatory compliance, and operational excellence. Success in the role includes delivering evidence-based determinations within established turnaround times, maintaining physician reviewer quality scores of 95% or greater, strengthening appeal defense, reducing avoidable overturns, resolving escalated disputes and complaints, coaching reviewers, improving review methodologies and quality controls, and contributing to client satisfaction and program growth.

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 or more years of clinical practice experience.
5 or more years of experience in payment integrity, utilization management, revenue cycle, health plan operations, auditing, or healthcare review.
Demonstrated physician-level review experience in clinical validation and DRG validation.
Demonstrated physician-level review experience in readmission and medical necessity reviews.
Demonstrated physician-level review experience in coding-related clinical reviews.
Demonstrated physician-level review experience in appeals and reconsiderations.
Demonstrated experience with peer-to-peer discussions and Medicare and 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, applicable payer policies, payment integrity methodologies, Revenue Cycle Management, medical necessity criteria, and appeals, grievances, and regulatory complaint processes.
Strong understanding of healthcare reimbursement methodologies and payer-provider payment processes.
Excellent written and verbal communication skills, including the ability to translate complex clinical determinations into clear, defensible rationale.
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.

Nice To Haves

Multi-state physician licensure.
Experience serving as a Medical Director, Associate Medical Director, Senior Medical Director, or Senior Physician Advisor.
Experience with Recovery Audit Contractor (RAC), Unified Program Integrity Contractor (UPIC), Medicaid Program Integrity, Medicare Advantage, or payment integrity vendors.
Certification or advanced training in healthcare quality, utilization management, risk adjustment, patient safety, or healthcare compliance.
Experience working with CMS, Medicare Advantage plans, Medicaid programs, commercial health plans, third-party administrators, or provider appeals organizations.

Responsibilities

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 to confirm accurate assignment and reimbursement.
Perform readmission reviews, including assessments of preventability, appropriateness, and documentation support.
Review escalated, high-dollar, high-risk, and clinically complex cases requiring physician-level judgment.
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 clear, evidence-based clinical rationale letters supporting determinations.
Participate in external review processes involving providers, health plans, clients, and regulatory agencies.
Respond to Medicare complaints, regulatory inquiries, Independent Review Organization requests, and other escalated appeal matters.
Provide expert clinical support during litigation, arbitration, audits, or formal dispute resolution activities, as required.
Ensure reviews comply with CMS regulations, Medicare guidelines, applicable state requirements, payer policies, clinical criteria, and industry standards.
Support quality assurance activities, reviewer calibration, internal audits, and client audit initiatives.
Help develop and maintain clinical review policies, methodologies, decision frameworks, and documentation standards.
Participate in audit-of-audit programs and continuous quality improvement initiatives.
Monitor appeal overturn trends, identify root causes, and recommend improvements to review quality and consistency.
Provide leadership, coaching, mentoring, and clinical oversight to physician reviewers, nurse reviewers, clinical validation specialists, and appeals staff.
Assist with hiring, onboarding, training, calibration, and performance development activities.
Support workforce planning, productivity monitoring, quality management, and operational performance.
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 as a clinical subject matter expert.
Present clinical findings, trends, and recommendations to clients and executive stakeholders.
Support implementation of new payment integrity programs, review initiatives, and client requirements.
Assist with review methodology development, scope expansion, and new program opportunities.
Collaborate with coding, analytics, quality, compliance, operations, and technology teams to improve review accuracy, efficiency, and outcomes.