Physician Reviewer

About the role

The Physician Reviewer evaluates clinical service requests submitted by members and providers, applying clinical expertise and organizational criteria to determine medical necessity and appropriateness of care. This role utilizes sound clinical judgment to support utilization management activities, identify opportunities for proactive case management, and contribute to quality improvement initiatives. The position does not provide direct patient care or medical diagnoses. Contract duration: 2 years, possible extension. Work arrangement: Remote.

Responsibilities

• Review and evaluate clinical service requests from members and providers using established medical criteria and clinical judgment.
• Adjudicate requests in accordance with organizational policies, guidelines, and utilization management standards.
• Identify opportunities to proactively manage complex member cases and anticipate potential future clinical needs.
• Collaborate with case managers to support anticipatory case management efforts.
• Participate in the review and appeal process for service denials.
• Assist in the development and maintenance of Physician Review Unit policies and procedures.
• Provide clinical leadership and consultation within the organization as needed.
• Actively participate in continuous quality improvement initiatives and departmental activities.
• Perform additional duties as assigned by the Medical Director.

Qualifications

• Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.).
• Board Certification through the American Board of Medical Specialties (ABMS).
• Unrestricted and active license to practice medicine.
• Minimum of five (5) years of clinical experience, including inpatient care experience, or an equivalent combination of education and experience.
• Knowledge and understanding of managed care principles and practices.
• Strong clinical assessment and decision-making skills.
• Proficiency with personal computers and electronic medical record/review systems, as most reviews are conducted electronically.

Skills

• Experience with utilization management, medical necessity reviews, or physician advisory services.
• Strong analytical and problem-solving abilities.
• Ability to work collaboratively with multidisciplinary healthcare teams.
• Excellent written and verbal communication skills.
• Experience participating in quality improvement and policy development initiatives.

Pay

$105/hour