Medical Reviewer

• 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

Medical Clinical Reviewer, MD/DO

• Conduct thorough reviews of clinical cases
• Evaluate medical records
• Provide clinical summaries
• Engage in peer communications
• Answer specific questions posed by clients
• Deliver advisory-only medical opinions without establishing a doctor/patient relationship or providing treatment

Medical Reviewer jobs in Virginia

Medical Clinical Reviewer, MD/DO

Board Certified Physician Reviewer – Medical Oncology