Medical Reviewer

Job Description

REQUIREMENTS

• 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.

RESPONSIBILITES

• 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.

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