Senior Physician Reviewer

MedReview Inc.

. Perform complex clinical validation reviews and provide final physician determinations on disputed findings .

Posted 11/4/2026full-timeRemote • United StatesSenior💰 $240,000 - $250,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive expertise in Clinical Validation, DRG Validation, and Payment Integrity methodologies, with a strong focus on compliance with CMS regulations and healthcare reimbursement processes. Proven ability to lead clinical review teams, manage physician-level appeals, and enhance operational efficiency through collaboration and training.

Highest-signal resume keywords

Clinical Validation ExpertiseDRG Validation ExperiencePayment Integrity MethodologiesLeadership in Clinical Review TeamsHealthcare Reimbursement Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ImprovementMedical Necessity ReviewsUtilization ManagementRevenue Cycle ManagementPeer-to-Peer DiscussionsRegulatory Complaint ResolutionCoding-Related Clinical ReviewsQuality AssuranceAudit ProcessesDecision Framework Development

Soft Skills

Excellent Communication SkillsProvider-Relations SkillsAnalytical ThinkingProblem-Solving CapabilitiesInfluencing Cross-Functional Teams

Certifications & Qualifications

Board Certification in Medical SpecialtyCertification in Healthcare QualityCertification in Utilization ManagementCertification in Healthcare Compliance

Industry Keywords

MedicareMedicaidCommercial Health PlansPayment IntegrityHealthcare OperationsClinical ReviewHealthcare AuditingRisk AdjustmentThird-Party AdministratorsProvider Appeals Organizations

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school
Active, unrestricted physician license in at least one U.S. state
Current board certification in an applicable medical specialty
Ability to obtain additional state licenses as business or client needs require
10+ years of clinical practice experience
5+ years of experience in payment integrity, utilization management, revenue cycle, health plan operations, auditing, or healthcare review
Physician-level review experience in clinical validation, DRG validation, readmission and medical necessity reviews, coding-related clinical reviews, appeals and reconsiderations, peer-to-peer discussions, and Medicare/regulatory complaint resolution
Experience supporting Commercial, Medicare Advantage, Medicaid, and other government healthcare programs
Prior leadership or supervisory experience supporting physician, nursing, clinical review, or healthcare operations teams
Expert knowledge of Clinical Documentation Improvement (CDI), clinical validation and DRG validation, Medicare rules, CMS requirements, payer policies, payment integrity methodologies, Revenue Cycle Management, medical necessity criteria, appeals, grievances, and regulatory complaint processes
Strong understanding of healthcare reimbursement methodologies and payer-provider payment processes
Excellent written and verbal communication skills
Exceptional provider-relations and peer-to-peer communication skills
Strong analytical, critical-thinking, and problem-solving capabilities
Ability to lead and influence cross-functional clinical and operational teams
Multi-state physician licensure preferred
Experience as a Medical Director, Associate Medical Director, Senior Medical Director, or Senior Physician Advisor preferred
Experience with RAC, UPIC, Medicaid Program Integrity, Medicare Advantage, or payment integrity vendors preferred
Certification or advanced training in healthcare quality, utilization management, risk adjustment, patient safety, or healthcare compliance preferred
Experience with CMS, Medicare Advantage plans, Medicaid programs, commercial health plans, third-party administrators, or provider appeals organizations preferred
Legally authorized to work in the United States without employer-sponsored visa assistance, now or in the future