[Hiring] Medical Clinical Reviewer Doctor @Integrity Management Services, Inc.

Role Description

The Medical Clinical Review Consultant provides professional medical expertise in support of healthcare claim reviews by conducting independent clinical evaluations of claims and supporting documentation, including medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and relevant claims data. The Consultant assesses medical necessity, clinical appropriateness, quality of care, and whether the documentation supports the services billed, and develops objective, well-supported clinical determinations in accordance with applicable Medicaid policies, coverage requirements, established clinical criteria, and generally accepted standards of medical practice.

Key Responsibilities

• Conduct independent clinical reviews of healthcare claims and supporting medical documentation.
• Review medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and other relevant clinical information.
• Evaluate services for medical necessity, clinical appropriateness, and consistency with generally accepted standards of medical practice.
• Assess whether the medical documentation supports the services, procedures, diagnoses, and level of care billed.
• Apply applicable Medicaid policies, coverage requirements, clinical criteria, and review guidelines when developing determinations.
• Identify potentially unnecessary, excessive, duplicative, unsupported, or otherwise questionable services based on the clinical documentation.
• Develop clear, objective, and well-supported clinical determinations and document the rationale for review findings.
• Respond to requests for clarification or additional clinical analysis regarding completed reviews.
• Escalate complex clinical or policy questions as appropriate and participate in clinical discussions when needed.
• Maintain consistency, accuracy, and objectivity across assigned reviews.
• Meet established quality, productivity, and project timelines.
• Maintain the confidentiality and security of protected health information and comply with applicable HIPAA and data security requirements.

Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
• Current, active, and unrestricted license to practice medicine in at least one U.S. state or jurisdiction.
• Medical license must be in good standing, with no current restrictions, suspensions, or disciplinary limitations that would affect the ability to perform clinical reviews.
• Minimum of two (2) years of professional clinical experience.
• Strong knowledge of medical terminology, clinical practice, treatment planning, medical documentation, and generally accepted standards of care, with the ability to interpret medical records, diagnostic results, imaging, treatment plans, and other clinical documentation.
• Strong analytical and critical-thinking skills with the ability to independently evaluate clinical information and develop objective, evidence-based clinical determinations.
• Ability to clearly and concisely document clinical review findings, conclusions, and supporting rationale.
• Strong attention to detail, organizational skills, and the ability to work independently while meeting established quality, productivity, and project timelines in a remote environment.

Preferred Qualifications

• Board certification or board eligibility in a medical specialty relevant to the assigned reviews.
• Experience in internal medicine, family medicine, psychiatry, or another specialty applicable to the review assignment.
• Experience treating Medicaid populations or working with Medicaid programs.
• Previous experience conducting medical record review, claims review, utilization review, medical necessity review, peer review, payment integrity review, or retrospective clinical review.
• Familiarity with Medicaid coverage policies, medical necessity requirements, and healthcare program integrity concepts.
• Experience evaluating potentially improper, excessive, unsupported, or medically unnecessary healthcare services.
• Familiarity with medical coding, including CPT/HCPCS and ICD-10-CM, and the relationship between clinical documentation and billed services.
• Experience supporting health plans, Medicaid agencies, Medicare, other government healthcare programs, or healthcare program integrity initiatives.

Compensation

U.S. remote annual hourly rate range: $80.00-$145.000. For candidates in jurisdictions requiring range disclosure, this is the good-faith range for this role; final pay may vary by work location and job-related factors such as skills, experience, location, and internal equity. This is not, however, a guarantee of compensation or salary. Rather, salary will be set based on experience, geographic location and possibly contractual requirements and could fall outside of this range.

Equal Opportunity Employer

IntegrityM is an Equal Opportunity Employer and we do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, and gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.