Physician Reviewer

W3R Consulting; Illinois; Hybrid; USD 150,000 - 230,000; Full time

Job summary

W3R Consulting in Illinois seeks a Board-Certified MD/DO to evaluate clinical service requests from members and providers, using clinical judgment and organizational criteria. The role does not involve direct patient care.

You will participate in the Physician Review Units' appeal process, help develop policies, and contribute to quality improvement efforts, with inpatient experience and managed care knowledge preferred.

Qualifications

• Board-certified MD/DO with active medical license.
• Minimum 5 years clinical experience including inpatient care.
• Familiarity with managed care and computer-based file review.

Responsibilities

• Evaluate clinical service requests using organization criteria.
• Provide clinical leadership in identified areas.
• Participate in Physician Review Units' appeal process.
• Contribute to policy and procedure development.
• Engage in unit continuous quality improvement activities.
• Other duties as assigned by Medical Director.

Skills

Clinical judgement

Decision making

Leadership

Quality improvement

Case management collaboration

Education

MD/DO (ABMS board certified)

Active unrestricted medical license

Tools

PC proficiency

Job description

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.)

Required Qualification:

Preferably Family Medicine, Internal Medicine, Rheumatology, Gastroenterology