Medical Clinical Reviewer, MD/DO

This is a fully remote position, open to applicants in Virginia.

📋 Description

• Perform independent clinical assessments of healthcare claims along with relevant medical documentation.

• Analyze medical records, treatment strategies, clinical notes, diagnostic evaluations, imaging results, procedural documentation, and pertinent clinical data.

• Assess the services for medical necessity, clinical relevance, and alignment with widely accepted medical practice standards.

• Evaluate whether the documentation adequately supports billed services, procedures, diagnoses, and levels of care.

• Implement Medicaid policies, coverage mandates, clinical criteria, and review protocols.

• Identify potentially unnecessary, excessive, duplicative, unsupported, or questionable services.

• Create objective, evidence-based clinical conclusions and document the rationale for reviews.

• Address requests for clarification or further clinical analysis.

• Escalate complex clinical or policy inquiries and engage in clinical discussions.

• Ensure consistency, accuracy, and objectivity in all assigned reviews.

• Achieve quality, productivity, and project deadlines.

• Safeguard the confidentiality and security of protected health information while adhering to HIPAA and data-security regulations.

⛳️ Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical institution.

• Current, active, and unrestricted medical license in at least one U.S. state or jurisdiction.

• Medical license must be in good standing, free of current restrictions, suspensions, or disciplinary actions affecting clinical reviews.

• At least two (2) years of professional clinical experience.

• Strong understanding of medical terminology, clinical practices, treatment planning, medical documentation, and generally accepted standards of care.

• Capability to interpret medical records, diagnostic findings, imaging, treatment plans, and other clinical documents.

• Excellent analytical and critical-thinking abilities.

• Ability to independently assess clinical information and formulate objective, evidence-based clinical conclusions.

• Proficiency in clearly and concisely documenting clinical review results, conclusions, and supporting reasoning.

• Strong attention to detail and organizational capabilities.

• Ability to work autonomously while meeting quality, productivity, and project deadlines in a remote setting.

• Preferred: board certification or eligibility in a relevant medical specialty.

• Preferred: experience in internal medicine, family medicine, psychiatry, or a related specialty.

• Preferred: experience working with Medicaid populations or Medicaid programs.

• Preferred: background in medical record review, claims review, utilization review, medical necessity review, peer review, payment integrity review, or retrospective clinical review.

• Preferred: familiarity with Medicaid coverage policies, medical necessity standards, and healthcare program integrity concepts.

• Preferred: experience in evaluating potentially improper, excessive, unsupported, or medically unnecessary healthcare services.

• Preferred: knowledge of CPT/HCPCS and ICD-10-CM coding, along with the connection between clinical documentation and billed services.

• Preferred: experience supporting health plans, Medicaid agencies, Medicare, government healthcare programs, or healthcare program integrity initiatives.

🏝️ Benefits

• U.S. remote annual hourly rate range: $80.00-$145.00.

• Flexible work environment.

• Opportunities for professional development.

• Commitment to equal opportunity employment.