Senior Physician Reviewer

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.
• 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.

• 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.

• 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.

Within 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.