Medical Reviewer (Durable Medical Equipment Specialist) - Remote CA

Medical Reviewer (Durable Medical Equipment Specialist) - Remote CA

It takes great medical minds to create powerful solutions that solve some of healthcare's most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you've honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you'll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Gainwell Technologies is seeking a Medical Reviewer (Durable Medical Equipment Specialist) to provide subject-matter expertise supporting Medical Review Services for California healthcare programs. In this role, you will review durable medical equipment (DME) claims, Treatment Authorization Requests (TARs), prescriptions, and supporting medical documentation to help ensure equipment and services meet applicable medical necessity, coverage, billing, and program requirements.

Your role in our mission:

• Review DME-related claims, Treatment Authorization Requests (TARs), prescriptions, and supporting medical documentation.
• Evaluate requests for durable medical equipment based on applicable medical policies, coverage requirements, and program guidelines.
• Review documentation supporting the medical necessity and appropriate use of durable medical equipment.
• Apply knowledge of DME products, supplies, billing practices, and healthcare reimbursement when completing reviews.
• Support claim adjudication and authorization activities involving DME.
• Document review findings, decisions, and supporting rationale accurately and timely.
• Identify documentation, billing, or coverage issues requiring additional review or clarification.
• Collaborate with clinicians, providers, operations teams, and other Medical Review Services professionals.
• Maintain knowledge of applicable DME policies, coverage requirements, billing practices, and regulatory guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.

What we're looking for:

• Minimum of three (3) years of professional experience working with Durable Medical Equipment (DME).
• Strong knowledge of DME products, equipment, supplies, and their uses.
• Management of a DME business and/or understanding of healthcare billing preferred.
• Ability to interpret medical documentation, prescriptions, claims, and supporting information.
• Strong analytical, documentation, written, and verbal communication skills.
• Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams.

What you should expect in this role:

• Full-time position.
• Remote work environment.
• Monday through Friday work schedule.
• Work primarily from your home office while supporting Medical Review Services for California healthcare programs.
• Spend the majority of your day reviewing DME claims, authorization requests, prescriptions, medical documentation, billing information, and supporting records.
• Work independently while collaborating with physicians, nurses, other clinical specialists, providers, operations teams, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain knowledge of applicable medical policies, DME coverage requirements, billing practices, and regulatory guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.
• Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.

This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.