Physician Reviewer
w3r Consulting
Description
Preferred Qualification(s):
- 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.)
- Board Certification in a Medical Specialty, active medical license. TX and NM license within 6 mo
Preferred Qualification(s):
- Orthopedics, Genetics, PMR, Allergy Immuniology, Rheumatology, plastic surgery, transplant, HemeOnc
Vacancy posted 4 days ago
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