Physician Reviewer

this positions is full-time Mon-Friday and possible weekend work as needed

this is remote in any of our five plan states, but IL and TX are preferred



Previous UM drug review experience is also preferred



Evaluates clinical service requests made by an organization's members and providers
Uses clinical judgment in conjunction with organization's criteria to adjudicate these requests
May also provide clinical leadership in other areas of the organization
Identifies opportunities to manage members' clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member
Participates in the process to evaluate clinical service requests
Practices anticipatory case management for members whose cases come for review, in partnership with case managers
Participates in the Physician Review Units' appeal process of service denials
Participates in the development of Physician Review Units' policies and procedures
Actively participates in all unit continuous quality improvement activities
Other duties as assigned by the Medical Director
Board Certified (ABMS) M.D
or D.O, unrestricted and active license to practice medicine requested and 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background
Must have understanding of managed care and demonstrate PC proficiency, as file review will be done via computer in most cases
(Note: Position does not provide direct patient care or medical diagnosis.)