Position: Physician Reviewer
Location: Nashville, TN (Remote- Must reside in TN, IL, MT, NM, OK, or TX)
Employment Type: Full-Time Contract
Pay: $120 per hour
Description: We’re seeking a Board-Certified M.D. or D.O. to join our team as a Physician Reviewer. In this role, you’ll apply clinical judgment to evaluate service requests, support case management, and contribute to continuous quality improvement initiatives. This is a non-clinical, remote position that plays a vital role in ensuring high-quality and efficient healthcare delivery.
Responsibilities:
- 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.
- 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 units’ continuous quality improvement activities.
- Other duties as assigned by the Medical Director.
Requirements:
- Board Certified (ABMS) M.D. or D.O, unrestricted and active license to practice medicine.
- 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background.
- Understanding of managed care.
- PC proficiency, as file review will be done via computer in most cases.
Note: This position does not provide direct patient care or medical diagnosis.