Physician Reviewer – Medicare Advantage Medical Record Review
Client Industry: Federal Healthcare and Medicare Program Support
Position: Physician Reviewer
Location: Remote
Employment Type: Full-time Contract
Our team is seeking an experienced Physician Reviewer to provide clinical expertise and physician-level medical guidance in support of Medicare Advantage medical record reviews, quality assurance activities, and appeals evaluations.
The Physician Reviewer will work closely with Lead Senior Coders, Quality Assurance Review Leads, medical coding professionals, compliance personnel, and program leadership to interpret complex clinical documentation and resolve questions involving diagnoses, treatments, procedures, and standards of care.
This opportunity is well suited for a licensed physician with experience in medical record review, clinical quality assurance, utilization review, appeals, healthcare audits, compliance, Medicare Advantage, or risk-adjustment programs.
Position Overview
The Physician Reviewer will provide clinical insight and medical guidance throughout the medical record review and appeals processes.
The selected physician will evaluate clinical documentation, determine whether reported diagnoses are supported by the medical record, assist with complex or escalated cases, and help ensure that review decisions are medically accurate, consistent, and aligned with applicable clinical and regulatory guidelines.
The Physician Reviewer will also participate in quality assurance panels, calibration sessions, case discussions, appeals reviews, training activities, and other program requirements.
Key Responsibilities
The Physician Reviewer will:
- Participate in clinical quality assurance panels, calibration sessions, and case review discussions.
- Provide physician-level clinical guidance to Lead Senior Coders, Quality Assurance Review Leads, and medical coding teams.
- Review medical records and supporting clinical documentation to resolve questions involving diagnoses, treatments, procedures, disease processes, and standards of care.
- Interpret complex, incomplete, conflicting, or unclear medical documentation.
- Provide clinical clarification when coding or quality assurance teams require additional medical guidance.
- Evaluate appeals documentation submitted by Medicare Advantage Organizations.
- Participate in appeals involving medical records, clinical findings, reported diagnoses, and supporting documentation.
- Determine whether the submitted documentation clinically supports reported diagnoses, conditions, and findings.
- Evaluate whether the medical record supports the clinical conclusions reached during the review process.
- Assist with disagreements, escalated cases, and complex matters involving coding, documentation, or clinical interpretation.
- Provide recommendations for resolving clinical discrepancies identified during medical record reviews.
- Support the development and consistent application of clinical review standards and quality assurance procedures.
- Document clinical findings, recommendations, and appeal determinations clearly and accurately.
- Ensure that clinical decisions are reasonable, consistent, defensible, and supported by the available medical documentation.
- Collaborate with coding, quality assurance, compliance, clinical, and program management personnel.
- Participate in program meetings, training sessions, calibration reviews, and other required activities.
- Maintain compliance with applicable privacy, security, confidentiality, healthcare, and program requirements.
- Protect all confidential information and protected health information in accordance with HIPAA requirements.
Required Qualifications
Qualified candidates must possess:
- A Doctor of Medicine degree or Doctor of Osteopathic Medicine degree from an accredited institution.
- A current and unrestricted license to practice medicine in the United States.
- Strong knowledge of medical terminology, diagnoses, treatments, procedures, disease processes, clinical documentation, and standards of care.
- Experience reviewing medical records for clinical accuracy, quality assurance, utilization review, appeals, audits, compliance, or related purposes.
- The ability to interpret complex medical and clinical information.
- The ability to determine whether reported diagnoses and conditions are supported by the medical record.
- The ability to clearly explain clinical findings to medical coders, quality assurance reviewers, program leadership, and non-clinical personnel.
- Strong analytical, critical-thinking, and decision-making skills.
- Strong written documentation and verbal communication skills.
- The ability to prepare clear, accurate, and defensible clinical findings and recommendations.
- The ability to work collaboratively with senior medical coders, quality assurance reviewers, clinical personnel, and program leadership.
- Strong attention to detail and a commitment to documentation accuracy.
- The ability to maintain the confidentiality of protected health information.
- Knowledge of HIPAA privacy and security requirements.
- Legal authorization to work in the United States.
Preferred Qualifications
The following experience is preferred but not required:
- Experience supporting Medicare or Medicare Advantage programs.
- Experience supporting the Centers for Medicare & Medicaid Services.
- Experience with Risk Adjustment Data Validation or similar healthcare audit programs.
- Experience conducting retrospective medical record reviews.
- Experience conducting medical necessity, utilization, claims, or appeals reviews.
- Familiarity with Medicare Advantage risk-adjustment documentation requirements.
- Familiarity with ICD-10-CM coding guidelines.
- Experience determining whether clinical documentation supports reported diagnoses.
- Previous experience working with certified medical coders, coding auditors, or clinical documentation improvement teams.
- Experience participating in clinical review panels, physician advisory committees, or quality assurance programs.
- Experience resolving complex or escalated clinical documentation cases.
- Board certification in a recognized medical specialty.
- Experience working within a federal healthcare program or government contracting environment.
Ideal Candidate Profile
The ideal candidate is:
- An experienced physician with sound clinical judgment.
- Skilled in interpreting complex and sometimes conflicting medical documentation.
- Comfortable evaluating medical records without providing direct patient care.
- Analytical, objective, and consistent when making clinical determinations.
- Able to clearly explain medical findings to both clinical and non-clinical personnel.
- Detail-oriented and committed to accurate documentation.
- Comfortable collaborating with certified medical coders and quality assurance professionals.
- Able to manage sensitive or disputed clinical cases professionally.
- Receptive to calibration, peer review, and quality assurance feedback.
- Dependable and disciplined about meeting review and documentation deadlines.
- Committed to maintaining professional integrity and confidentiality.
- Able to work effectively within a multidisciplinary and highly regulated program environment.
Core Competencies
Successful candidates will demonstrate strength in:
- Clinical judgment and medical record interpretation
- Medicare Advantage medical record review
- Quality assurance and regulatory compliance
- Appeals evaluation and case resolution
- Diagnosis and documentation validation
- Clinical analysis and decision-making
- Clear written and verbal communication
- Documentation accuracy and attention to detail
- Collaboration with multidisciplinary teams
- Professional integrity and confidentiality
Working Relationships
The Physician Reviewer will work closely with:
- Lead Senior Coders
- Quality Assurance Review Leads
- Medical Coders and Coding Audit Teams
- Clinical Review Personnel
- Program and Project Leadership
- Compliance and Quality Assurance Personnel
- Clinical Subject-Matter Experts
- Client and government stakeholders, as required
- Other program personnel involved in medical record and appeals reviews
Work Environment
The selected Physician Reviewer will support a collaborative, quality-focused program environment that emphasizes:
- Accurate and consistent medical record review.
- Defensible clinical findings and appeal determinations.
- Collaboration between physicians, medical coders, and quality assurance personnel.
- Standardized review and calibration procedures.
- Compliance with healthcare privacy, security, and confidentiality requirements.
- Timely completion of assigned reviews and documentation.
- Continuous quality improvement and professional accountability.
Why Join This Opportunity?
- Apply your medical expertise in a non-direct-patient-care environment.
- Support an important Medicare Advantage medical record review program.
- Collaborate with experienced physicians, medical coders, quality assurance reviewers, and program leaders.
- Help resolve complex clinical documentation and appeals matters.
- Contribute to accurate, consistent, and defensible medical review decisions.
- Participate in quality assurance panels and multidisciplinary case discussions.
- Support the development and consistent application of clinical review standards.
- Work within a professional, collaborative, and mission-focused program environment.
Application Requirements
Qualified candidates are encouraged to submit:
- A current résumé or curriculum vitae.
- A brief cover letter or statement of interest.
- Medical degree information.
- Current medical license information, including the licensing state and expiration date.
- Board certification information, when applicable.
- A summary of relevant medical record review, utilization review, appeals, audit, or quality assurance experience.
- Details regarding Medicare, Medicare Advantage, CMS, RADV, or risk-adjustment experience.
- Current availability.
- Earliest available start date.
- Preferred employment arrangement, when multiple options are available.
Please submit your application through the PAC Group LLC website or email your résumé or curriculum vitae and statement of interest to patrick@gopacgroup.com or info@gopacgroup.com.
LinkedIn: https://www.linkedin.com/in/pacgroupllc