- This position requires an initial time commitment to undergo and complete training. After training, physician medical reviewer will provide weekend coverage, 8-hour shifts per Saturday and/or Sunday per month. This is a remote position.
- Physician medical reviewer evaluates clinical service requests based on company guidelines to make medical necessity determinations.
- Must be board Certified, M.D. or D.O with an unrestricted physician license in a state or territory of the United States. Must demonstrate basic computer skills.
- 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 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.
- 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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Physician Reviewer - Chicago, United States - Innovative Systems Group
Description
Major Healthcare company
100% Remote from any state, except California or New York
Seeking physician medical reviewer for REMOTE weekend work - at least 2 weekends per month
Required Qualification(s):
MD or DO, ABMS Board Certified
(Note: Position does not provide direct patient care or diagnostic evaluation)
Responsibilities:
