Senior Physician Reviewer

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

📋 Description

• Conduct intricate clinical validation assessments and deliver final determinations from physicians on contested findings.

• Evaluate and confirm diagnoses, severity of illness, risk adjustment factors, clinical documentation, medical necessity, and issues related to reimbursement.

• Execute DRG validation and reviews of clinical documentation.

• Carry out readmission assessments focusing on preventability, appropriateness, and documentation support.

• Review escalated cases that are high-dollar, high-risk, and clinically complex.

• Offer specialty-specific clinical insights for both inpatient and outpatient payment integrity evaluations.

• Oversee physician-level appeals concerning clinical validation, DRG validation, medical necessity, and other findings related to payment integrity.

• Engage in peer-to-peer discussions with treating physicians and hospital representatives.

• Draft and assess evidence-based clinical rationale letters.

• Take part in external review processes involving providers, health plans, clients, and regulatory bodies.

• Address Medicare complaints, regulatory inquiries, Independent Review Organization requests, and escalated appeals.

• Provide clinical assistance during litigation, arbitration, audits, and formal dispute resolutions.

• Ensure that reviews adhere to CMS regulations, Medicare guidelines, state mandates, payer policies, clinical criteria, and industry standards.

• Support quality assurance, reviewer calibration, internal audits, client audits, audit-of-audit programs, and ongoing quality improvement initiatives.

• Develop and uphold clinical review policies, methodologies, decision frameworks, and standards for documentation.

• Monitor trends in appeal overturns, identify root causes, and propose enhancements.

• Lead, coach, mentor, and provide clinical supervision to physician reviewers, nurse reviewers, clinical validation specialists, and appeals personnel.

• Assist in the processes of hiring, onboarding, training, calibration, performance development, workforce planning, productivity tracking, and quality management.

• Act 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 initiatives.

• Present clinical findings, trends, and recommendations to both clients and executive stakeholders.

• Support the implementation of payment integrity programs and meet client requirements.

• Assist in the development of methodologies, expansion of scope, and exploration of new program opportunities.

• Collaborate with coding, analytics, quality, compliance, operations, and technology teams to enhance accuracy, efficiency, and outcomes.

• Deliver physician determinations within established turnaround times and service-level expectations.

• Maintain physician reviewer quality scores of 95% or higher.

• Fortify appeal defenses, enhance decision consistency, and minimize avoidable overturns.

• Cultivate reviewer capabilities through coaching, training, and clinical oversight.

• Contribute to client satisfaction, program expansion, and initiatives for MedReview growth.

⛳️ Requirements

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

• An active, unrestricted physician license in at least one U.S. state.

• Current board certification in a relevant medical specialty.

• Capability to obtain additional state licenses as required by business or client needs.

• Over 10 years of clinical practice experience.

• At least 5 years of experience in payment integrity, utilization management, revenue cycle, health plan operations, auditing, or healthcare review.

• Experience in physician-level reviews concerning clinical validation, DRG validation, readmission and medical necessity evaluations, coding-related clinical assessments, appeals and reconsiderations, peer-to-peer discussions, and Medicare/regulatory complaint resolutions.

• Background in supporting Commercial, Medicare Advantage, Medicaid, and other government healthcare programs.

• Prior leadership or supervisory roles within physician, nursing, clinical review, or healthcare operations teams.

• In-depth knowledge of Clinical Documentation Improvement (CDI), clinical validation and DRG validation, Medicare regulations, CMS requirements, payer policies, methodologies for payment integrity, Revenue Cycle Management, criteria for medical necessity, appeals, grievances, and regulatory complaint procedures.

• Strong comprehension of healthcare reimbursement methodologies and payer-provider payment processes.

• Excellent written and verbal communication abilities.

• Outstanding provider-relations and peer-to-peer communication skills.

• Strong analytical, critical-thinking, and problem-solving skills.

• Capacity to lead and influence cross-functional clinical and operational teams.

• Multi-state physician licensure is preferred.

• Experience in roles such as Medical Director, Associate Medical Director, Senior Medical Director, or Senior Physician Advisor is preferred.

• Familiarity with RAC, UPIC, Medicaid Program Integrity, Medicare Advantage, or vendors in payment integrity is preferred.

• Certification or advanced training in healthcare quality, utilization management, risk adjustment, patient safety, or healthcare compliance is preferred.

• Experience with CMS, Medicare Advantage plans, Medicaid programs, commercial health plans, third-party administrators, or provider appeals organizations is preferred.

• Legally authorized to work in the United States without employer-sponsored visa assistance, now or in the future.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and training.

• Collaborative and supportive work environment.

• Flexible working arrangements.