Medical Clinical Reviewer Doctor (MD/DO) (Part-time, Remote)

Medical Clinical Review Consultant

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review.

At IntegrityM, we offer a culture of opportunity, recognition, collaboration, and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees' professional development. Large company perksSmall company feel!

The Medical Clinical Review Consultant provides professional medical expertise in support of healthcare claim reviews by conducting independent clinical evaluations of claims and supporting documentation, including medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and relevant claims data. The Consultant assesses medical necessity, clinical appropriateness, quality of care, and whether the medical documentation supports the services billed, and develops objective, well-supported clinical determinations in accordance with applicable Medicaid policies, coverage requirements, established clinical criteria, and generally accepted standards of medical practice.

Key responsibilities include:

• Conducting independent clinical reviews of healthcare claims and supporting medical documentation.
• Reviewing medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and other relevant clinical information.
• Evaluating services for medical necessity, clinical appropriateness, and consistency with generally accepted standards of medical practice.
• Assessing whether the medical documentation supports the services, procedures, diagnoses, and level of care billed.
• Applying applicable Medicaid policies, coverage requirements, clinical criteria, and review guidelines when developing determinations.
• Identifying potentially unnecessary, excessive, duplicative, unsupported, or otherwise questionable services based on the clinical documentation.
• Developing clear, objective, and well-supported clinical determinations and documenting the rationale for review findings.
• Responding to requests for clarification or additional clinical analysis regarding completed reviews.
• Escalating complex clinical or policy questions as appropriate and participating in clinical discussions when needed.
• Maintaining consistency, accuracy, and objectivity across assigned reviews.
• Meeting established quality, productivity, and project timelines.
• Maintaining the confidentiality and security of protected health information and complying with applicable HIPAA and data security requirements.