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

About the role

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

Responsibilities

• 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.

Requirements

• 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.

Qualifications

• 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.

Skills

• Strong clinical judgment and ability to interpret medical records and supporting clinical documentation.

Benefits

• 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%.

Pay

The pay range for this position is $100,000 - $120,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Schedule

Monday through Friday work schedule.

Benefits

• Flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Education assistance.

Company Information

• Gainwell Technologies is an Equal Opportunity Employer.
• Gainwell Technologies defines wages and wage rates to include all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.