Physician Reviewer

Overview

• Review medical appropriateness of services using evidence-based guidelines and clinical expertise.
• Provide clinical determinations and document decisions in workflow tools for member clarity.
• Conduct peer-to-peer discussions with providers to clarify clinical information and review outcomes.
• Ensure compliance with applicable laws and regulations in all review processes.
• Participate in call rotation and occasional travel for team meetings and events.
• Work remotely within designated states, maintaining high-quality standards.
• Collaborate with the Associate Medical Director for utilization management.
• Engage in continuous improvement and adherence to organizational policies.

Key Responsibilities & Duties

• Provide timely medical reviews adhering to stringent quality parameters.
• Document communication and decision-making clearly for member reference.
• Utilize correct templates for documentation during case reviews.
• Meet turnaround times for clinical reviews and escalated cases.
• Conduct peer-to-peer discussions to clarify clinical information and review outcomes.
• Provide feedback on alternate treatments based on evidence-based research.
• Ensure compliance with laws, regulations, and internal policies.
• Participate in team meetings and contribute to organizational goals.

Job Requirements

• Doctor of Medicine (MD) with board certification as an MD or DO.
• Licensed in FL or NC, or eligible for Interstate Medical Licensure Compact (IMLCC).
• Minimum 6 years of clinical practice and 1 year of utilization review experience.
• Experience in care management within the health insurance industry preferred.
• Licensure in multiple states and willingness to obtain additional licensure.
• Board certification in Cardiology, Radiation/Oncology, or Neurology is a plus.
• Strong documentation skills and ability to use workflow tools effectively.
• Commitment to compliance and evidence-based clinical practices.