Medical Clinical Review Consultant

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.

The Role

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.

Key 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

Required Qualifications

• 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 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

• 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.