Physician Reviewer

Job Title: Physician Reviewer

Location: Remote

Duration: 2+years of contract position (possible extension + Contract to hire)

Schedule: 40hr/ per week and 5 days week (Mon- Fri – 8.00 to 5.00 pm)

Job 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.