Physician Reviewer

W3R Consulting; Town of Texas (WI); Hybrid; USD 180,000 - 240,000; Full time

Job summary

W3R Consulting seeks a physician to evaluate clinical service requests and adjudicate with clinical judgment, providing leadership in the organization’s clinical operations. You will participate in case reviews, anticipate member needs, and contribute to policy development and quality improvement activities.

Requirements include Board Certified (ABMS) MD or DO with unrestricted license and at least 5 years of clinical experience, including inpatient work; familiarity with managed care and

Qualifications

• Adjudicate clinical service requests based on judgment and criteria.
• Understand managed care principles and apply them to denials and approvals.
• Provide clinical leadership and participate in policy development and QA.

Responsibilities

• Evaluate clinical service requests and rules-based adjudication.
• Participate in Physician Review Units' appeal processes.
• Lead anticipatory case management with case managers and other stakeholders.
• Contribute to development of unit policies and procedures.
• Engage in continuous quality improvement activities.

Skills

Clinical adjudication

Managed care understanding

PC proficiency

Inpatient experience

Education

MD/DO degree

Tools

EMR systems

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.)