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

Summary

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. In this role, you will 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.

Your role in our mission

• Review claims, Treatment Authorization Requests (TARs), prescriptions, and supporting documentation involving prosthetic and orthotic devices.
• Evaluate prosthetic and orthotic requests based on applicable coverage requirements, medical policies, and professional standards.
• Assess 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.

What we're looking for

• 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.

What you should expect in this role

• 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.
• Work independently while collaborating 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%.

This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.

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