Medical Reviewer; Physician; Remote CA

Medical Reviewer (Physician) - Remote CA

It takes great medical minds to create powerful solutions that solve some of healthcare's most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you've honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you'll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards.

You'll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

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.

Your role in our mission:

• 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.

What we're looking for:

• 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.

What you should expect in this role:

• Full-time position.
• Remote work environment.
• Monday through Friday work schedule.
• Work primarily from your home office while supporting Medical Review Services for California healthcare programs.
• Spend the majority of your day reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to your area of expertise.
• Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• 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.
• Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.
• Travel requirement: 0-10%.

The pay range for this position is $140,000 - $160,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work 'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance.

We also have a variety of leadership and technical development academies to help build your skills and capabilities.