Medical Reviewer (Prosthetic and Orthotic Devices Specialist) - Remote CA (West

About the role

Gainwell Technologies is seeking a Medical Reviewer (Prosthetic and Orthotic Devices Specialist) to provide subject-matter expertise supporting Medical Review Services for California healthcare programs.

Responsibilities

• Review prosthetic and orthotic device requests, claims, Treatment Authorization Requests (TARs), prescriptions, and supporting documentation to help ensure services and devices meet applicable coverage, medical necessity, and program requirements.
• Evaluate prosthetic and orthotic requests based on applicable coverage requirements, medical policies, and professional standards.
• Absess documentation supporting the medical need and appropriate use of prosthetic and orthotic devices.
• Provide subject-matter expertise related to prosthetic and orthotic equipment, services, and practices.
• Support claim adjudication and authorization activities involving prosthetic and orthotic services.
• Document review findings, decisions, and supporting rationale accurately and timely.
• Identify documentation or coverage issues requiring additional review or clarification.
• Collaborate with clinicians, providers, operations teams, and other Medical Review Services specialists.
• Maintain knowledge of applicable prosthetic and orthotic standards, coverage requirements, policies, and regulatory guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.

Requirements

• Professional experience as a Prosthetic and Orthotic (P&O) practitioner consistent with program requirements.
• Certification in Prosthetics and Orthotics.
• Ownership or management of a Prosthetic and Orthotic business within the past five (5) years preferred.
• Strong knowledge of prosthetic and orthotic devices, services, and clinical applications.
• Ability to interpret medical documentation, prescriptions, and supporting device information.
• Strong analytical, written, and verbal communication skills.
• Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams.

Qualifications

• Professional experience as a Prosthetic and Orthotic (P&O) practitioner consistent with program requirements.
• Certification in Prosthetics and Orthotics.
• Ownership or management of a Prosthetic and Orthotic business within the past five (5) years preferred.
• Strong knowledge of prosthetic and orthotic devices, services, and clinical applications.
• Ability to interpret medical documentation, prescriptions, and supporting device information.
• Strong analytical, written, and verbal communication skills.
• Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams.

Skills

• Ability to interpret medical documentation, prescriptions, and supporting device information.
• Strong analytical, written, and verbal communication skills.
• Ability to work independently while collaborating effectively with clinical, operational, and cross-functional teams.

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 prosthetic and orthotic claims, authorization requests, prescriptions, medical documentation, and supporting information.
• Collaborate with physicians, nurses, other clinical specialists, operations teams, providers, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain all professional certifications and credentials required for the position in active and good-standing status, as applicable.
• Maintain knowledge of applicable medical policies, coverage requirements, professional 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 $70,000 - $90,000 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.