Physician Appeals Reviewer ($150/hr-$180/hr)-245506

Medix™; Estados Unidos; A distancia; COP 40.000.000 - 80.000.000; Jornada completa

Descripción de la vacante

A leading healthcare organization is seeking an experienced Physician Reviewer to join their clinical review team. This remote position involves reviewing clinical documentation for appeals and grievances, focusing on Medicare populations. The ideal candidate will have a medical license, board certification, and experience in clinical practice, ensuring thorough, evidence-based assessments are completed in a timely manner.

Formación

• 3–5 years of clinical practice experience.
• Strong understanding of medical necessity criteria.
• Familiarity with Medicare guidelines and documentation.

Responsabilidades

• Review clinical documentation and case records for appeals and grievances.
• Assess medical necessity and appropriateness of care.
• Draft clear, concise written rationales for case decisions.

Conocimientos

Clinical review

Evidence-based assessment

Regulatory compliance understanding

Strong clinical judgment

Educación

MD or DO with an active license

Board Certification in Internal Medicine or Family Medicine

Descripción del empleo

A leading healthcare organization is seeking an experienced and detail-oriented Physician Reviewer to join their clinical review team. This role focuses on reviewing clinical documentation for appeals and grievances, with an emphasis on Medicare populations. Ideal candidates will have strong clinical judgment, familiarity with regulatory requirements, and the ability to provide thorough, evidence-based assessments in a timely manner.

This is a remote position with flexible scheduling, ideal for physicians looking to transition into or expand their experience in utilization management, medical review, or health plan operations.

Position Overview

Key Responsibilities:

• Review clinical documentation and case records for appeals and grievances related to denied services, primarily for Medicare patients.
• Assess the medical necessity and appropriateness of care using evidence-based guidelines and clinical judgment.
• Render determinations in accordance with CMS regulations, NCQA/URAC standards, and internal policies.
• Draft clear, concise, and well-supported written rationales for all case decisions.
• Conduct peer-to-peer discussions with attending providers, when appropriate.
• Ensure all case reviews are completed within required timelines set by the organization and applicable regulations.
• Collaborate with other internal teams such as medical directors, case managers, and compliance/legal teams.
• Maintain up-to-date knowledge of clinical guidelines, CMS rules, and industry changes.
• Handle all patient data with the highest level of confidentiality.

Qualifications

Required:

• MD or DO with an active, unrestricted medical license in CA, AZ, NV, TX, or NC
• Board Certification in Internal Medicine or Family Medicine (preferred)
• 3–5 years of clinical practice experience
• Strong understanding of medical necessity criteria (e.g., MCG, InterQual), CMS regulations, and managed care environments

Preferred:

• Experience in utilization management, peer review, appeals/grievances, or health plan operations
• Multi-state licensure or compact state license
• Familiarity with Medicare guidelines and documentation requirements

Compensation

$150.00/hr - $180.00/hr

Seniority level

Not Applicable

Employment type

Full-time

Job function

Health Care Provider

Hospitals and Health Care