医学临床评审医生（MD/DO）
Medical Clinical Reviewer Doctor (MD/DO)
**关于我们**
[www.integritym.com](https://www.integritym.co)
Integrity Management Services, Inc. (IntegrityM) 是一家获奖的、由女性拥有的小型企业，专注于帮助政府和商业客户在合规和项目完整性方面的工作，包括预防和发现政府项目中的欺诈、浪费和滥用行为。通过数据分析、技术解决方案、审计、调查和医疗审查实现成果。
在 IntegrityM，我们提供一个充满机会、认可、协作并支持社区的文化。我们依靠这些基本要素，使 IntegrityM 成为一个优秀的工作场所。我们灵活的小型工作环境提供了卓越的生活质量，并推动以公司为导向的可持续发展。我们提供创新的解决方案，超越目标，并营造一个充满活力、以想法驱动的环境，促进员工的职业发展。拥有大公司的福利……但有小公司的感觉！
**职位概述**
医疗临床审查顾问为医疗费用审查提供专业医疗专业知识，通过独立进行临床评估来审查费用和支持文件，包括医疗记录、治疗计划、临床笔记、诊断测试、影像资料、手术记录和相关费用数据。该顾问评估医疗必要性、临床适当性、护理质量，以及文档是否支持所申报的服务，并根据适用的医疗补助政策、覆盖要求、既定的临床标准和普遍接受的医疗实践标准，制定客观且有依据的临床判断。
**主要职责**
- 独立审查医疗费用和支持的医疗文档。
- 审查医疗记录、治疗计划、临床笔记、诊断测试、影像资料、手术记录和其他相关临床信息。
- 评估服务的医疗必要性、临床适当性以及与普遍接受的医疗实践标准的一致性。
- 评估医疗文档是否支持所申报的服务、程序、诊断和护理水平。
- 在制定判断时应用适用的医疗补助政策、覆盖要求、临床标准和审查指南。
- 根据临床文档识别可能不必要的、过度的、重复的、无依据的或存在疑问的服务。
查看英文原文
**About Us**
[www.integritym.com](https://www.integritym.co)
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. Large company perks…Small company feel!
**Position Summary**
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.