Physician Reviewer

Innovative Systems Group; Dallas (TX); On-site; USD 180,000 - 240,000; Full time

Job summary

Innovative Systems Group seeks a physician reviewer to evaluate clinical service requests using clinical judgment and organization criteria. This role collaborates with case managers, participates in denial appeal processes, and helps shape Physician Review Units' policies.

Necessitates board-certified MD/DO with unrestricted license and at least five years of clinical experience including inpatient care. No direct patient care is provided by this position.

Qualifications

• Board certified ABMS MD/DO with unrestricted license.
• Minimum 5 years of clinical experience including inpatient experience.
• Strong understanding of managed care and PC proficiency.
• Position does not provide direct patient care or medical diagnosis.

Responsibilities

• Evaluate clinical service requests using clinical judgment.
• Participate in anticipatory case management for members after review.
• Contribute to Physician Review Units' appeal process for denials.
• Assist in policy & procedure development for Physician Review Units.
• Engage in continuous quality improvement activities within the unit.

Skills

Clinical judgment

Managed care understanding

PC proficiency

Education

ABMS board-certified MD/DO

Job description

.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.

• 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.)