Medical Reviewer, Physician

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

📋 Description

• Conduct physician-level medical evaluations of claims, Treatment Authorization Requests (TARs), appeals, and various clinical documents.

• Utilize medical knowledge, relevant policies, coverage criteria, and clinical benchmarks when making or supporting review decisions.

• Offer technical and clinical insights regarding suspended claims, appeals, provider inquiries, and other medical review processes.

• Assist in the interpretation and development of medical policies as necessary.

• Provide clinical expertise in drug utilization reviews when assigned.

• Accurately document medical review outcomes and the clinical rationale behind them.

• Collaborate with pharmacists, nurses, other healthcare professionals, operations teams, and business partners.

• Keep abreast of relevant Medicaid, Medicare, California healthcare programs, and regulatory standards.

• Adhere to established standards for quality, accuracy, productivity, timeliness, and turnaround times.

• Primarily work from a home office to support California healthcare initiatives.

• Navigate various computer systems and applications to complete reviews, document findings, and facilitate timely decisions.

• Travel requirement ranges from 0% to 10%.

⛳️ Requirements

• Must possess a current, non-expired physician license from the State of California, in good standing.

• Should not be under suspension from Medicare, Medicaid, or the practice of medicine in California.

• Must not have a history of sanctions for fraud or abuse.

• Requires 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 support for the entire suspended claims process, appeals process, and provider relations; or three (3) years of experience in drug utilization review.

• Excellent oral and written communication skills are essential.

• Strong clinical judgment with the ability to interpret complex medical documentation is required.

• Must maintain all professional licenses, certifications, and credentials necessary for the position in active, unrestricted, and good standing, as applicable.

🏝️ Benefits

• Flexible working hours.

• Work-life balance.

• Opportunities for continuous learning and career development.

• Generous and flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.

• Ongoing training and support.

• Remote work environment.