In this fully remote contract role, the clinician reviews clinical service requests from members and providers and uses medical judgment and payer criteria to determine whether services meet coverage requirements. The work is focused on utilization management and appeal review rather than direct patient care or diagnosis. The role may also involve clinical leadership, policy input, and quality improvement activities.
Key Responsibilities
- Evaluate clinical service requests using organizational criteria and clinical judgment.
- Participate in review of service denials through the physician review appeals process.
- Identify opportunities to support members’ care needs and anticipate future clinical issues.
- Contribute to development of review-unit policies and procedures.
- Participate in continuous quality improvement activities.
- Use computer-based workflows to complete file review and documentation.
- Perform additional duties as assigned by the Medical Director.
Required
- MD or DO degree.
- Board certification through ABMS.
- Active, unrestricted medical license.
- At least 5 years of clinical experience, including inpatient experience.
- Understanding of managed care.
- Strong computer proficiency for electronic file review.
Preferred
- Experience in utilization management or payer review.
- Background in clinical leadership or policy development.
- Experience with appeal review processes.
Benefits & Perks
- Fully remote work arrangement.
- Contract assignment lasting 18 months.
- Part-time to full-time schedule flexibility of 20-40 hours per week.
- Possible weekend coverage in a rotation.