Job Description
About MedReview
MedReview is a leading provider of payment integrity solutions that help national and regional health plans promote population health, ensure payment accuracy, reduce administrative waste, improve provider relationships, and optimize financial performance. For more than four decades, MedReview has partnered with health plans, third-party administrators, and other healthcare organizations to deliver technology-enabled solutions that identify savings opportunities, drive operational efficiency, and improve healthcare outcomes.
The Opportunity
We are seeking a Senior Physician Reviewer reporting to the Senior Medical Director to serve as a physician leader and clinical subject matter expert for complex payment integrity reviews, clinical validation determinations, DRG validation, readmission reviews, appeals, peer-to-peer discussions, and regulatory complaint resolution. This role provides physician-level judgment on disputed, high-dollar, high-risk, and clinically complex matters and serves as a supervisory and consultative resource to physician reviewers, nurse auditors, coders, quality teams, operations, and client-facing leaders.
The Senior Physician Reviewer applies deep clinical expertise, regulatory knowledge, and payment integrity experience to deliver accurate, defensible, and compliant determinations across Commercial, Medicare Advantage, Medicaid, and other government-sponsored healthcare programs. The role is critical to maintaining clinical quality, provider credibility, client satisfaction, regulatory compliance, and operational excellence.
Key Responsibilities
Clinical Review Leadership
- 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 to confirm accurate assignment and reimbursement.
- Perform readmission reviews, including assessments of preventability, appropriateness, and documentation support.
- Review escalated, high-dollar, high-risk, and clinically complex cases requiring physician-level judgment.
- Provide specialty-specific clinical expertise for inpatient and outpatient payment integrity reviews.
Appeals and Regulatory Management
- 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 clear, evidence-based clinical rationale letters supporting determinations.
- Participate in external review processes involving providers, health plans, clients, and regulatory agencies.
- Respond to Medicare complaints, regulatory inquiries, Independent Review Organization requests, and other escalated appeal matters.
- Provide expert clinical support during litigation, arbitration, audits, or formal dispute resolution activities, as required.
Quality and Compliance
- Ensure reviews comply with CMS regulations, Medicare guidelines, applicable state requirements, payer policies, clinical criteria, and industry standards.
- Support quality assurance activities, reviewer calibration, internal audits, and client audit initiatives.
- Help develop and maintain clinical review policies, methodologies, decision frameworks, and documentation standards.
- Participate in audit-of-audit programs and continuous quality improvement initiatives.
- Monitor appeal overturn trends, identify root causes, and recommend improvements to review quality and consistency.
Leadership and Supervision
- Provide leadership, coaching, mentoring, and clinical oversight to physician reviewers, nurse reviewers, clinical validation specialists, and appeals staff.
- Assist with hiring, onboarding, training, calibration, and performance development activities.
- Support workforce planning, productivity monitoring, quality management, and operational performance.
- 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 as a clinical subject matter expert.
Client and Operational Support
- Present clinical findings, trends, and recommendations to clients and executive stakeholders.
- Support implementation of new payment integrity programs, review initiatives, and client requirements.
- Assist with review methodology development, scope expansion, and new program opportunities.
- Collaborate with coding, analytics, quality, compliance, operations, and technology teams to improve review accuracy, efficiency, and outcomes.
Qualifications
Education and Licensure
- 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.
Experience
- 10+ years of clinical practice experience.
- 5+ years of experience in payment integrity, utilization management, revenue cycle, health plan operations, auditing, or healthcare review.
- Demonstrated physician-level review experience in the areas listed below:
- Clinical validation and DRG validation
- Readmission and medical necessity reviews
- Coding-related clinical reviews
- Appeals and reconsiderations
- Peer-to-peer discussions
- Medicare and 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.
Knowledge and Skills
- Expert knowledge in the areas listed below:
- Clinical Documentation Improvement (CDI)
- Clinical validation and DRG validation
- Medicare rules, CMS requirements, and applicable payer policies
- Payment integrity methodologies and 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, including the ability to translate complex clinical determinations into clear, defensible rationale.
- 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.
Preferred Experience
- Multi-state physician licensure.
- Experience serving as a Medical Director, Associate Medical Director, Senior Medical Director, or Senior Physician Advisor.
- Experience with Recovery Audit Contractor (RAC), Unified Program Integrity Contractor (UPIC), Medicaid Program Integrity, Medicare Advantage, or payment integrity vendors.
- Certification or advanced training in healthcare quality, utilization management, risk adjustment, patient safety, or healthcare compliance.
- Experience working with CMS, Medicare Advantage plans, Medicaid programs, commercial health plans, third-party administrators, or provider appeals organizations.
What Success Looks LikeWithin the first 12 to 24 months, this role will:
- Deliver high-quality, evidence-based, and defensible physician determinations while meeting established 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 through calibration and root-cause analysis.
- Ensure timely resolution of escalated provider disputes, peer-to-peer matters, and regulatory complaints.
- Build reviewer capability through effective coaching, training, and clinical oversight.
- Improve review methodologies, quality controls, and cross-functional operational processes.
- Contribute to client satisfaction, program expansion, and MedReview growth initiatives as a credible physician leader.
Compensation - $240,000 - $250,000
