Physician Reviewer

Physician Reviewer

Schedule is M-F, but may need to work 3-4 weekends per year remote, but must reside within one of our plan states - TX/OK/NM/IL/MT/TN

Job Responsibilities:

• 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.
• 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.

Education & Experience Requirements:

• 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.

Required Qualification(s):

• Board Certification in a Medical Specialty, active medical license.
• TX and NM license within 6 months.

Specialties:

• Orthopedics.
• Genetics.
• PMR.
• Allergy Immunology.
• Rheumatology.
• Plastic Surgery.
• Transplant.
• Heme Oncology.

Note:

• Position does not provide direct patient care or medical diagnosis.