This physician reviewer role focuses on evaluating medical service requests and appeals using clinical judgment and utilization management criteria. It is fully remote and centered on chart review rather than direct patient care or diagnosis. The work may also include clinical leadership, policy development, and quality improvement activities.
Key Responsibilities
- Evaluate clinical service requests from members and providers against organizational criteria.
- Review appeal cases related to service denials.
- Use clinical judgment and file review to support utilization management decisions.
- Identify opportunities to help manage members’ clinical situations and anticipate future needs.
- Participate in development of policies and procedures for the physician review unit.
- Contribute to continuous quality improvement activities.
- Provide additional clinical leadership support as assigned by the Medical Director.
Required
- Board-certified M.D. or D.O. by ABMS.
- Active, unrestricted medical license.
- At least 5 years of clinical experience, including inpatient experience.
- Understanding of managed care.
- Proficiency with computer-based documentation and file review.
Preferred
- Experience in utilization management or medical review.
- Prior experience with appeals or policy development.
Benefits & Perks
- Fully remote work arrangement.
- Contract duration of 18 months.
- Part-time to full-time schedule range of 20 to 40 hours per week.
- Possible weekend coverage in a rotation.