About MedReview
MedReview is a leading provider of payment integrity solutions that help national and regional health plans promote population health, ensure payment accuracy, reduce administrative waste, improve provider relationships, and optimize financial performance. For more than four decades, MedReview has partnered with health plans, third-party administrators, and other healthcare organizations to deliver technology-enabled solutions that identify savings opportunities, drive operational efficiency, and improve healthcare outcomes.
The Opportunity
We are seeking a Senior Physician Reviewer reporting to the Senior Medical Director to serve as a physician leader and clinical subject matter expert for complex payment integrity reviews, clinical validation determinations, DRG validation, readmission reviews, appeals, peer-to-peer discussions, and regulatory complaint resolution. This role provides physician-level judgment on disputed, high-dollar, high-risk, and clinically complex matters and serves as a supervisory and consultative resource to physician reviewers, nurse auditors, coders, quality teams, operations, and client-facing leaders.
The Senior Physician Reviewer applies deep clinical expertise, regulatory knowledge, and payment integrity experience to deliver accurate, defensible, and compliant determinations across Commercial, Medicare Advantage, Medicaid, and other government-sponsored healthcare programs. The role is critical to maintaining clinical quality, provider credibility, client satisfaction, regulatory compliance, and operational excellence.
Key Responsibilities
Clinical Review Leadership Perform complex clinical validation reviews and provide final physician determinations on disputed findings.
Review and validate diagnoses, severity of illness, risk adjustment factors, clinical documentation, medical necessity, and reimbursement-related issues.
Conduct DRG validation and clinical documentation reviews to confirm accurate assignment and reimbursement.
Perform readmission reviews, including assessments of preventability, appropriateness, and documentation support.
Review escalated, high-dollar, high-risk, and clinically complex cases requiring physician-level judgment.
Provide specialty-specific clinical expertise for inpatient and outpatient payment integrity reviews.
Appeals and Regulatory Management Manage physician-level appeals involving clinical validation, DRG validation, medical necessity, and other payment integrity findings.
Conduct peer-to-peer discussions with treating physicians and hospital representatives.
Prepare and review clear, evidence-based clinical rationale letters supporting determinations.
Participate in external review processes involving providers, health plans, clients, and regulatory agencies.
Respond to Medicare complaints, regulatory inquiries, Independent Review Organization requests, and other escalated appeal matters.
Provide expert clinical support during litigation, arbitration, audits, or formal dispute resolution activities, as required.
Quality and Compliance Ensure reviews comply with CMS regulations, Medicare guidelines, applicable state requirements, payer policies, clinical criteria, and industry standards.
Support quality assurance activities, reviewer calibration, internal audits, and client audit initiatives.
Help develop and maintain clinical review policies, methodologies, decision frameworks, and documentation standards.
Participate in audit-of-audit programs and continuous quality improvement initiatives.
Monitor appeal overturn trends, identify root causes, and recommend improvements to review quality and consistency.
Leadership and Supervision Provide leadership, coaching, mentoring, and clinical oversight to physician reviewers, nurse reviewers, clinical validation specialists, and appeals staff.
Assist with hiring, onboarding, training, calibration, and performance development activities.
Support workforce planning, productivity monitoring, quality…