Medical Reviewer (Optometrist) - Remote CA (West Sacramento, CA, US, 95605-1630)

Summary

Gainwell Technologies is seeking a Medical Reviewer (Optometrist) to provide professional optometric expertise supporting Medical Review Services for California healthcare programs.

Your role in our mission

• Review optometry-related medical records, claims, Treatment Authorization Requests (TARs), and supporting clinical documentation.
• Evaluate requested services against applicable medical policies, coverage requirements, and clinical standards.
• Apply professional optometric expertise when supporting medical necessity and coverage determinations.
• Document findings and clinical rationale accurately and timely.
• Refer cases requiring additional clinical review to appropriate medical professionals.
• Collaborate with clinical and operational partners to resolve review questions.
• Maintain knowledge of applicable policies and regulatory requirements.
• Meet established quality, accuracy, productivity, and turnaround-time standards.

What we're looking for

• Minimum of one (1) year of experience working as an Optometrist.
• Doctor of Optometry degree from an accredited school of Optometry.
• Current, non-expired California license to practice as an Optometrist, in good standing.
• Must not be under suspension from Medicare, Medicaid, or practice in California.
• Must not have been previously sanctioned for fraud or abuse.
• Strong oral and written communication skills.
• Strong clinical judgment and ability to interpret medical records and supporting clinical documentation.

What you should expect in this role

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 optometry-related medical, clinical, claim, authorization, and supporting documentation.
• Work independently while collaborating with physicians, nurses, other clinical specialists, operations teams, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status.
• Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, 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.
• Travel requirement: 0-10%.

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