Provides physician-level medical review for California healthcare programs, reviewing claims, treatment authorization requests, appeals, and supporting clinical documentation. The work focuses on applying medical policy, coverage requirements, and clinical standards to help support timely review determinations. This is a remote, full-time role with regular collaboration across pharmacists, nurses, physicians, and operations teams.
Key Responsibilities
- Conduct physician-level reviews of claims, TARs, appeals, and other clinical documentation.
- Apply medical expertise, coverage requirements, and clinical standards to review determinations.
- Provide clinical support for suspended claims, provider inquiries, and related medical review activities.
- Support medical policy interpretation and development as needed.
- Provide clinical expertise for drug utilization review when assigned.
- Document review findings and clinical rationale clearly and accurately.
- Collaborate with pharmacists, nurses, other clinicians, operations teams, and business partners.
- Maintain awareness of Medicaid, Medicare, California program, and regulatory requirements.
Required
- Current, non-expired California physician license in good standing.
- Three years of experience as a medical consultant for a government or private-sector healthcare payer; or one year of MMIS experience supporting suspended claims, appeals, and provider relations; or three years of drug utilization review experience.
- Strong oral and written communication skills.
- Strong clinical judgment and ability to interpret complex medical documentation.
- 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.
Preferred
- Experience working with Medicaid and Medicare program requirements.
- Experience supporting medical policy, claim adjudication, or appeals review.
- Experience working in a payer or MMIS environment.
Benefits & Perks
- Remote work environment.
- Flexible Monday through Friday schedule.
- Flexible vacation policy for salaried, full-time employees.
- 401(k) employer match.
- Comprehensive health benefits.
- Educational assistance.
- Leadership and technical development academies.
- Pay range of $140,000 to $160,000 per year.