In this remote contract role, the physician reviews clinical service requests from members and providers, applying clinical judgment and managed care criteria to determine appropriate care. The work focuses on case review, anticipatory case management, and appeal support, with some opportunity to contribute to clinical leadership and process improvement.
Key Responsibilities
- Evaluate clinical service requests and use clinical criteria to support determinations.
- Review cases in partnership with case managers to identify opportunities for proactive clinical management.
- Participate in the appeal process for service denials.
- Contribute to physician review policies, procedures, and continuous quality improvement activities.
- Provide clinical leadership and other duties as assigned by the Medical Director.
- Use computer-based file review workflows to assess documentation and case details.
Required
- Board certified MD or DO.
- Unrestricted and active medical license.
- At least 5 years of clinical experience, including inpatient experience.
- Understanding of managed care.
- Proficiency with computer-based work and electronic file review.
Preferred
- Experience in utilization review, case review, or related physician reviewer work.
- Experience contributing to quality improvement or policy development.
Benefits & Perks
- Remote work arrangement.
- Contract assignment with a 24-month duration.
- Weekend-focused schedule after full-time weekday training.
- Possible holiday coverage based on client needs.