Responsibilities:
· 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. Other duties as assigned by the Medical Director.
Job Requirements:
· 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.)
Job Types: Full-time, Contract
Pay: $100,000.00 - $120,000.00 per year

Benefits:

• Health insurance

Location:

• Remote (Required)

Work Location: Remot

Please refer the Job description for details