Medical Clinical Reviewer, MD/DO

Integrity Management Services, Inc.

. Conduct independent clinical reviews of healthcare claims and supporting medical documentation .

Posted 9/25/2026part-timeRemote • Virginia • United StatesJuniorMid-Level💰 $80 - $145 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in conducting clinical reviews of healthcare claims, ensuring compliance with Medicaid policies, and applying clinical criteria to evaluate medical necessity. Possesses strong analytical skills and attention to detail, with the ability to document findings and maintain confidentiality in accordance with HIPAA regulations.

Highest-signal resume keywords

Doctor Of Medicine (MD) Or Doctor Of Osteopathic Medicine (DO)Medical License In Good StandingClinical Review ExperienceKnowledge Of Medical TerminologyAnalytical And Critical-Thinking Skills

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical ReviewMedical Record ReviewClaims ReviewUtilization ReviewMedical Necessity ReviewCPT/HCPCS CodingICD-10-CM CodingEvidence-Based Clinical DeterminationsTreatment PlanningDocumentation Of Clinical Findings

Soft Skills

Attention To DetailOrganizational SkillsIndependent WorkCommunication SkillsProblem-Solving Skills

Certifications & Qualifications

Board Certification Or Board Eligibility In A Relevant Medical Specialty

Industry Keywords

Medicaid PoliciesHealthcare ClaimsClinical AppropriatenessHealthcare Program IntegrityProtected Health InformationHIPAA ComplianceMedical Necessity RequirementsClinical DocumentationDiagnostic TestingImaging

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

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 in good standing, with no current restrictions, suspensions, or disciplinary limitations affecting 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
Ability to interpret medical records, diagnostic results, imaging, treatment plans, and other clinical documentation
Strong analytical and critical-thinking skills
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 and organizational skills
Ability to work independently while meeting quality, productivity, and project timelines in a remote environment
Preferred: board certification or board eligibility in a relevant medical specialty
Preferred: experience in internal medicine, family medicine, psychiatry, or another applicable specialty
Preferred: experience treating Medicaid populations or working with Medicaid programs
Preferred: medical record review, claims review, utilization review, medical necessity review, peer review, payment integrity review, or retrospective clinical review experience
Preferred: familiarity with Medicaid coverage policies, medical necessity requirements, and healthcare program integrity concepts
Preferred: experience evaluating potentially improper, excessive, unsupported, or medically unnecessary healthcare services
Preferred: familiarity with CPT/HCPCS and ICD-10-CM coding and the relationship between clinical documentation and billed services
Preferred: experience supporting health plans, Medicaid agencies, Medicare, government healthcare programs, or healthcare program integrity initiatives

Benefits

Comp & perks

U.S. remote annual hourly rate range: $80.00-$145.00
Flexible workplace
Professional development opportunities
Equal opportunity employment