California Licensed Medical Reviewer

Job Summary

Supporting Medical Review Services for California healthcare programs, the full-time California Licensed Medical Reviewer will perform physician-level medical reviews of claims, Treatment Authorization Requests (TARs), and appeals while working remotely.

Key responsibilities

• Conduct physician-level medical reviews of clinical documentation, claims, and appeals
• Apply medical expertise and clinical standards to support review determinations
• Collaborate with healthcare professionals and maintain knowledge of relevant regulatory requirements

Required qualifications

• Current, non-expired physician license from the State of California in good standing
• Three years of experience as a medical consultant for a healthcare payer or one year of MMIS experience
• Experience in drug utilization review is preferred
• Strong clinical judgment and ability to interpret complex medical documentation
• Must not be under suspension from Medicare, Medicaid, or the practice of medicine in California