Role: Sr. Medical Reviewer
Location: (100% Remote)
Duration: 12+ months (Remote)
Skills & Experience:
Fully Remote, but MUST reside in either TX or IL
Required hours: Monday through Friday, 8a-6p intermittent occasional coverage of weekend shifts
MUST have an ACTIVE Medical/Doctor License to practice in the state they reside
MUST have 10+ years clinical experience with managed care and utilization management
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 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.)