MedReview Inc.

Physician

• Perform complex clinical validation reviews and provide final physician determinations on disputed findings
• Review and validate diagnoses, severity of illness, risk adjustment factors, clinical documentation, medical necessity, and reimbursement-related issues
• Conduct DRG validation and clinical documentation reviews
• Perform readmission reviews assessing preventability, appropriateness, and documentation support
• Review escalated, high-dollar, high-risk, and clinically complex cases
• Provide specialty-specific clinical expertise for inpatient and outpatient payment integrity reviews
• Manage physician-level appeals involving clinical validation, DRG validation, medical necessity, and other payment integrity findings
• Conduct peer-to-peer discussions with treating physicians and hospital representatives
• Prepare and review evidence-based clinical rationale letters
• Participate in external review processes with providers, health plans, clients, and regulatory agencies
• Respond to Medicare complaints, regulatory inquiries, Independent Review Organization requests, and escalated appeals
• Provide clinical support during litigation, arbitration, audits, and formal dispute resolution
• Ensure reviews comply with CMS regulations, Medicare guidelines, state requirements, payer policies, clinical criteria, and industry standards
• Support quality assurance, reviewer calibration, internal audits, client audits, audit-of-audit programs, and continuous quality improvement
• Develop and maintain clinical review policies, methodologies, decision frameworks, and documentation standards
• Monitor appeal overturn trends, identify root causes, and recommend improvements
• Lead, coach, mentor, and provide clinical oversight to physician reviewers, nurse reviewers, clinical validation specialists, and appeals staff
• Assist with hiring, onboarding, training, calibration, performance development, workforce planning, productivity monitoring, and quality management
• Serve as a clinical consultant to Operations, Account Management, Client Services, Implementation, Quality, Compliance, and executive leadership
• Participate in client meetings, operational reviews, and business development activities
• Present clinical findings, trends, and recommendations to clients and executive stakeholders
• Support implementation of payment integrity programs and client requirements
• Assist with methodology development, scope expansion, and new program opportunities
• Collaborate with coding, analytics, quality, compliance, operations, and technology teams to improve accuracy, efficiency, and outcomes
• Deliver physician determinations within turnaround times and service-level requirements
• Maintain physician reviewer quality scores of 95% or greater
• Strengthen appeal defense, improve decision consistency, and reduce avoidable overturns
• Build reviewer capability through coaching, training, and clinical oversight
• Contribute to client satisfaction, program expansion, and MedReview growth initiatives

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Senior Physician Reviewer