Medical Clinical Reviewer Doctor (MD/DO) (Part-time, Remote)
Integrity Management Services, Inc. · Alexandria, VA · 1 mo ago
Analyst$80–$145/hrPart-time
We need to output HTML fragment with sections: About the role? Actually the posting includes "About Us" then "Position Summary" then "Key Responsibilities", "Requirements", "Preferred Qualifications", "Benefits". We need to use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). We must not repeat job title as heading. We need to include sections only when posting has real specific content. We need to preserve all substantive info, no boilerplate. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. The posting includes an EEO statement at end: "IntegrityM is an Equal Opportunity Employer...". That's boilerplate; we should remove it. Also "Benefits" section includes pay range. We need to include Pay? The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we should have About the role heading with content from About Us and Position Summary. Then Responsibilities heading with Key Responsibilities content. Then Requirements heading with Required Qualifications content. Then Qualifications heading with Preferred Qualifications content. Benefits heading with pay range. We should not include Skills unless there is specific skills content; we have some skills in Requirements but we can keep them under Requirements. We'll not create Skills section.
We need to use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). We must not repeat job title as heading. We need to include sections only when posting has real specific content. We need to preserve all substantive info, no boilerplate. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. The posting includes an EEO statement at end: "IntegrityM is an Equal Opportunity Employer...". That's boilerplate; we should remove it. Also "Benefits" section includes pay range. We need to include Pay? The instruction: Use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). We should include Benefits heading if there is content. There's a Benefits section with pay range. Also maybe we can include Pay heading separate? But they said prefer few substantive sections over many thin ones. So we could combine Benefits and Pay into one Benefits section that includes pay range. Or we could have Benefits and Pay separate if both have content. The posting includes "U.S. remote annual hourly rate range: $80.00-$145.000". That's pay info. It also says "Benefits" heading but only includes pay range; no other benefits described. So we could have a Benefits section that includes the pay range. Or we could have Pay section. Since they gave example headings, we can choose Benefits. We'll include Benefits
with
Benefits
withcontaining the pay range info. Also we need About the role? The posting has "About Us" and "Position Summary". We could combine into About the role section. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we should have About the role heading with content from About Us and Position Summary. Then Responsibilities heading with Key Responsibilities content. Then Requirements heading with Required Qualifications content. Then Qualifications heading with Preferred Qualifications content. Benefits heading with pay range. We should not include Skills unless there is specific skills content; we have some skills in Requirements but we can keep them under Requirements. We'll not create Skills section.
We need to use - for any list of duties/requirements/benefits. So for Responsibilities, we need to convert each responsibility into
- . For Requirements (required qualifications) we need list. For Preferred Qualifications also list. For Benefits maybe just a paragraph.
We must preserve all substantive information; do not invent or summarize away detail. So we need to keep all details from each bullet.
Let's extract content.
About Us paragraph: "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 perks…Small company feel!"
Position Summary: "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 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."
We can combine these into About the role section.
Key Responsibilities list (each sentence seems a bullet). Let's list them:
- Conduct independent clinical reviews of healthcare claims and supporting medical documentation.
- Review medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and other relevant clinical information.
- Evaluate services for medical necessity, clinical appropriateness, and consistency with generally accepted standards of medical practice.
- Assess whether the medical documentation supports the services, procedures, diagnoses, and level of care billed.
- Apply applicable Medicaid policies, coverage requirements, clinical criteria, and review guidelines when developing determinations.
- Identify potentially unnecessary, excessive, duplicative, unsupported, or otherwise questionable services based on the clinical documentation.
- Develop clear, objective, and well-supported clinical determinations and document the rationale for review findings.
- Respond to requests for clarification or additional clinical analysis regarding completed reviews.
- Escalate complex clinical or policy questions as appropriate and participate in clinical discussions when needed.
- Maintain consistency, accuracy, and objectivity across assigned reviews.
- Meet established quality, productivity, and project timelines.
- Maintain the confidentiality and security of protected health information and comply with applicable HIPAA and data security requirements.
We need to keep each as
- .
Requirements (Required Qualifications) list:
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
- Current, active, and unrestricted license to practice medicine in at least one U.S. state or jurisdiction.
- Medical license must be in good standing, with no current restrictions, suspensions, or disciplinary limitations that would affect the ability to perform clinical reviews.
- Minimum of two (2) years of professional clinical experience.
- Strong knowledge of medical terminology, clinical practice, treatment planning, medical documentation, and generally accepted standards of care, with the ability to interpret medical records, diagnostic results, imaging, treatment plans, and other clinical documentation.
- Strong analytical and critical-thinking skills with the ability to independently evaluate clinical information and develop objective, evidence-based clinical determinations.
- Ability to clearly and concisely document clinical review findings, conclusions, and supporting rationale.
- Strong attention to detail, organizational skills, and the ability to work independently while meeting established quality, productivity, and project timelines in a remote environment.
Preferred Qualifications list:
- Board certification or board eligibility in a medical specialty relevant to the assigned reviews.
- Experience in internal medicine, family medicine, psychiatry, or another specialty applicable to the review assignment.
- Experience treating Medicaid populations or working with Medicaid programs.
- Previous experience conducting medical record review, claims review, utilization review, medical necessity review, peer review, payment integrity review, or retrospective clinical review.
- Familiarity with Medicaid coverage policies, medical necessity requirements, and healthcare program integrity concepts.
- Experience evaluating potentially improper, excessive, unsupported, or medically unnecessary healthcare services.
- Familiarity with medical coding, including CPT/HCPCS and ICD-10-CM, and the relationship between clinical documentation and billed services.
- Experience supporting health plans, Medicaid agencies, Medicare, other government healthcare programs, or healthcare program integrity initiatives.
Benefits: "U.S. remote annual hourly rate range: $80.00-$145.000 For candidates in jurisdictions requiring range disclosure, this is the good-faith range for this role; final pay may vary by work location and job-related factors such as skills, experience, location, and internal equity. This is not, however, a guarantee of compensation or salary. Rather, salary will be set based on experience, geographic location and possibly contractual requirements and could fall outside of this range."
We need to keep that as a paragraph under Benefits heading. Possibly we could also note that it's hourly rate range. Keep as is.
We must not include EEO statement. Remove.
We must not include any duplicated lines. Ensure we don't repeat.
Now produce HTML fragment:
About the role
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 perks…Small 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 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.
Responsibilities
- Conduct independent clinical reviews of healthcare claims and supporting medical documentation.
- Review medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and other relevant clinical information.
- Evaluate services for medical necessity, clinical appropriateness, and consistency with generally accepted standards of medical practice.
- Assess whether the medical documentation supports the services, procedures, diagnoses, and level of care billed.
- Apply applicable Medicaid policies, coverage requirements, clinical criteria, and review guidelines when developing determinations.
- Identify potentially unnecessary, excessive, duplicative, unsupported, or otherwise questionable services based on the clinical documentation.
- Develop clear, objective, and well-supported clinical determinations and document the rationale for review findings.
- Respond to requests for clarification or additional clinical analysis regarding completed reviews.
- Escalate complex clinical or policy questions as appropriate and participate in clinical discussions when needed.
- Maintain consistency, accuracy, and objectivity across assigned reviews.
- Meet established quality, productivity, and project timelines.
- Maintain the confidentiality and security of protected health information and comply with applicable HIPAA and data security requirements.
Requirements
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
- Current, active, and unrestricted license to practice medicine in at least one U.S. state or jurisdiction.
- Medical license must be in good standing, with no current restrictions, suspensions, or disciplinary limitations that would affect the ability to perform clinical reviews.
- Minimum of two (2) years of professional clinical experience.
- Strong knowledge of medical terminology, clinical practice, treatment planning, medical documentation, and generally accepted standards of care, with the ability to interpret medical records, diagnostic results, imaging, treatment plans, and other clinical documentation.
- Strong analytical and critical-thinking skills with the ability to independently evaluate clinical information and develop objective, evidence-based clinical determinations.
- Ability to clearly and concisely document clinical review findings, conclusions, and supporting rationale.
- Strong attention to detail, organizational skills, and the ability to work independently while meeting established quality, productivity, and project timelines in a remote environment.
Qualifications
- Board certification or board eligibility in a medical specialty relevant to the assigned reviews.
- Experience in internal medicine, family medicine, psychiatry, or another specialty applicable to the review assignment.
- Experience treating
About the role
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 perks…Small 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 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.
Responsibilities
- Conduct independent clinical reviews of healthcare claims and supporting medical documentation.
- Review medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and other relevant clinical information.
- Evaluate services for medical necessity, clinical appropriateness, and consistency with generally accepted standards of medical practice.
- Assess whether the medical documentation supports the services, procedures, diagnoses, and level of care billed.
- Apply applicable Medicaid policies, coverage requirements, clinical criteria, and review guidelines when developing determinations.
- Identify potentially unnecessary, excessive, duplicative, unsupported, or otherwise questionable services based on the clinical documentation.
- Develop clear, objective, and well-supported clinical determinations and document the rationale for review findings.
- Respond to requests for clarification or additional clinical analysis regarding completed reviews.
- Escalate complex clinical or policy questions as appropriate and participate in clinical discussions when needed.
- Maintain consistency, accuracy, and objectivity across assigned reviews.
- Meet established quality, productivity, and project timelines.
- Maintain the confidentiality and security of protected health information and comply with applicable HIPAA and data security requirements.
Requirements
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
- Current, active, and unrestricted license to practice medicine in at least one U.S. state or jurisdiction.
- Medical license must be in good standing, with no current restrictions, suspensions, or disciplinary limitations that would affect the ability to perform clinical reviews.
- Minimum of two (2) years of professional clinical experience.
- Strong knowledge of medical terminology, clinical practice, treatment planning, medical documentation, and generally accepted standards of care, with the ability to interpret medical records, diagnostic results, imaging, treatment plans, and other clinical documentation.
- Strong analytical and critical-thinking skills with the ability to independently evaluate clinical information and develop objective, evidence-based clinical determinations.
- Ability to clearly and concisely document clinical review findings, conclusions, and supporting rationale.
- Strong attention to detail, organizational skills, and the ability to work independently while meeting established quality, productivity, and project timelines in a remote environment.
Qualifications
- Board certification or board eligibility in a medical specialty relevant to the assigned reviews.
- Experience in internal medicine, family medicine, psychiatry, or another specialty applicable to the review assignment.
- Experience treating