Physician Reviewer

Job Title: Physician Reviewer
Contract Duration: 2 years, possible extension
Work Arrangement: Remote in any state except NY, CA, HI or AK
Pay Rate: $115.00/hour

Summary
The Physician Reviewer evaluates clinical service requests submitted by members and providers, applying clinical expertise and established organizational criteria to make medical necessity determinations. This role supports quality patient care through clinical review, case management collaboration, appeals participation, and continuous quality improvement initiatives. This position does not provide direct patient care or render medical diagnoses.

Key Responsibilities

• Review and evaluate clinical service requests from members and providers using clinical judgment and organizational guidelines.
• Identify opportunities to proactively manage members' clinical situations through creative problem-solving and anticipation of potential future healthcare needs.
• Participate in the review and determination process for clinical service requests.
• Collaborate with case managers to support anticipatory case management and care coordination.
• Participate in the appeals process related to service denials.
• Contribute to the development and enhancement of Physician Review Unit policies and procedures.
• Actively engage in continuous quality improvement activities within the department.
• Provide clinical leadership and expertise as needed across the organization.
• Perform additional duties as assigned by the Medical Director.

• Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree.
• Board Certification through the American Board of Medical Specialties (ABMS).
• Current, active, and unrestricted license to practice medicine.
• Minimum of five (5) years of clinical experience, including inpatient care experience, or an equivalent combination of education and experience.
• Strong understanding of managed care principles and utilization management processes.
• Proficiency with computer systems and technology, as clinical reviews are primarily conducted electronically.

Additional Information

• This is a non-patient-facing role.
• The position does not involve direct patient care or medical diagnosis.
• Reviews and documentation are completed primarily through computer-based systems.