In this role, the physician reviews medical necessity cases for care management, appeals, prior authorization, and quality-of-care complaints, with decisions informed by clinical guidelines and utilization data. The work also includes technology assessment, benefit determination, pharmacy-related review, and support for case management and committee processes. This is a remote, part-time leadership role with significant collaboration across nurses, committees, and network physicians.
Key Responsibilities
- Conduct medical necessity reviews for standard and expedited pre-service, concurrent, and post-service cases.
- Review and decide clinical appeals, including expedited and routine requests.
- Conduct quality-of-care complaint reviews for clinical and service-related issues.
- Participate in technology assessment, benefit determination, and medical policy discussions.
- Support care management programs, utilization review, and identification of over-, under-, and mis-utilization trends.
- Participate in committee work, including Clinical Appeals, Technology Assessment, and Benefit Implementation activities.
- Coordinate with nurses and other clinical staff through grand rounds, inter-rater reliability processes, and on-call coverage as needed.
- Review coding appeals, facility claims audits, and denial reviews for ER services.
Required
- MD or DO degree.
- Active physician license with current board certification in an ABMS-recognized specialty.
- Unrestricted medical license.
- At least 10 years of experience beyond the medical degree.
- At least 5 years of leadership experience.
- Willingness and ability to obtain medical licensure in additional states as needed.
Preferred
- Experience with pre-service, concurrent, and post-service review.
- Experience in case management and appeals review.
- Knowledge of pharmacy and therapeutics processes, including formulary development and utilization review.
- Strong written, verbal, and communication skills.
- Strong collaboration, process management, and technical aptitude.
- Experience representing clinical perspectives on committees and speaking with network physicians.
Benefits & Perks
- Remote work arrangement.
- Part-time schedule.
- Competitive salary range is stated in the posting.
- Medical, dental, and vision coverage.
- PTO and holidays.
- Paid volunteer time off.
- 401(k) contributions.
- Caregiver services and additional employee benefits.