Job Description

🌟 We're Hiring: Physician Reviewer (Utilization Review)! 🌟

We are seeking a dedicated and experienced ABMS Board Certified MDs/DOs to join our team, focusing on pre-service reviews/prior authorizations. The ideal candidate will possess a strong clinical background and the ability to evaluate medical necessity, ensuring that care is appropriate and cost-effective.

Job Title: Physician Reviewer

Client: Managed Care Org/Heath Insurance

Location: Nashville, TN - Fully remote – Work from Home 

Contract: 1-year, contract to hire

Schedule: Monday-Friday, 8am-5pm CST

Training period for the first 2 weeks

Description:

• Evaluates clinical service requests made by an organization's members and providers. Uses clinical judgment in conjunction with organization's criteria to adjudicate these requests.
• May also provide clinical leadership in other areas of the organization. Identifies opportunities to manage members' clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member.
• Participates in the process to evaluate clinical service requests.
• Practices anticipatory case management for members whose cases come for review, in partnership with case managers.
• Participates in the Physician Review Units' appeal process of service denials.
• Participates in the development of Physician Review Units' policies and procedures.
• Actively participates in all unit continuous quality improvement activities.
• Other duties as assigned by the Medical Director.

Required Qualifications:

• Board Certified (ABMS) M.D. or D.O, unrestricted and active license to practice medicine requested and 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background.
• Must have understanding of managed care and demonstrate PC proficiency, as file review will be done via computer in most cases. (Note: Position does not provide direct patient care or medical diagnosis.)

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