Physician Reviewer

Job Title: Physician Reviewer 

Job Summary

The Physician Reviewer is responsible for evaluating clinical service requests submitted by members and providers, utilizing medical expertise and established organizational criteria to make determinations. This role supports utilization management processes, contributes to policy development, and participates in appeals and quality improvement initiatives. This is a non-patient-facing position with no direct clinical care or diagnosis responsibilities.

Schedule & Compensation

• Hours: 20–40 hours per week
• Schedule: Flexible, with potential weekend rotation coverage
• Pay Rate: $105 – $115/hour
• Work Arrangement: Fully remote (Not available in CA, NY, HI, or AK)

Key Responsibilities

• Review and evaluate clinical service requests to determine medical necessity based on established guidelines
• Apply clinical judgment in conjunction with organizational criteria to approve, modify, or deny requests
• Participate in the Physician Review Unit (PRU) appeal process for service denials
• Provide clinical insight and leadership to support utilization management activities
• Identify opportunities for proactive and creative management of members’ clinical situations
• Contribute to the development and enhancement of clinical policies and procedures
• Support continuous quality improvement (CQI) initiatives within the review unit
• Collaborate with internal teams and Medical Director to ensure consistent and compliant decision-making
• Perform additional duties as assigned

Qualifications

• Education:

  • Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.)

• Certifications & Licensure:

  • Board Certified through ABMS
  • Active, unrestricted medical license required
  • Preferred: Licensure in New Mexico (NM) and/or Oklahoma (OK)

• Experience:

  • Minimum 5 years of clinical experience, including inpatient care
  • Prior utilization management or peer review experience preferred
  • Experience in managed care strongly preferred

Technical Skills

• Strong understanding of managed care principles and utilization review processes
• Proficiency with computers and clinical systems; ability to perform reviews electronically
• Familiarity with evidence-based guidelines and medical necessity criteria