Medical Reviewer; Laboratory Specialist; 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 (Laboratory Specialist) to provide laboratory subject-matter expertise supporting Medical Review Services for California healthcare programs. In this role, you will review laboratory-related claims, Treatment Authorization Requests (TARs), orders, and supporting documentation to help ensure laboratory services meet applicable coverage, medical necessity, and program requirements.

• Review laboratory-related claims, Treatment Authorization Requests (TARs), orders, and supporting documentation.
• Evaluate laboratory services based on applicable medical policies, coverage requirements, and program guidelines.
• Apply laboratory expertise when reviewing the appropriateness of requested or billed laboratory services.
• Support claim adjudication and medical review activities involving laboratory testing.
• Review supporting documentation for completeness and alignment with applicable program requirements.
• Document review findings, decisions, and supporting rationale accurately and timely.
• Identify documentation, billing, or coverage issues requiring additional review or clarification.
• Collaborate with clinical, operational, provider-facing, and other Medical Review Services teams to resolve laboratory review questions.
• Maintain knowledge of applicable laboratory practices, medical policies, coverage requirements, and healthcare program guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.

• Minimum of two (2) years of experience as a laboratory technician.
• High school diploma or equivalent.
• Completion of a Medical Laboratory Technician program from an accredited medical laboratory technician school.
• Knowledge of laboratory procedures, terminology, testing, and documentation.
• Ability to interpret laboratory-related records, orders, claims, and supporting documentation.
• Strong analytical, written, and verbal communication skills.
• Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams.

• 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 laboratory-related claims, authorization requests, orders, medical documentation, and supporting records.
• Work independently while collaborating with physicians, nurses, other clinical specialists, operations teams, providers, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain all professional certifications and credentials required for the position in active and good-standing status, as applicable.
• Maintain knowledge of applicable medical policies, laboratory practices, coverage requirements, 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.
• Tra…