Physician Reviewer

VIVA USA Inc; United States; On-site; USD 200,000 - 300,000; Full time

Job summary

VIVA USA Inc. seeks a Board-certified MD or DO to adjudicate clinical service requests and provide clinical leadership in Physician Review Units. The role requires weekends and possible holiday shifts, with full-time training Monday–Friday.

Proficiency with computer-based file reviews and a solid understanding of managed care are essential. The position emphasizes quality improvement and policy development within the unit.

Qualifications

• Board-certified MD or DO with unrestricted license and at least 5 years of clinical experience, including inpatient care.
• Understanding of managed care and ability to perform file reviews via computer.
• Willing to work every weekend and on holidays; available for full-time training M-F.
• Strong clinical judgment and ability to provide leadership across the organization.

Responsibilities

• Evaluate clinical service requests and adjudicate using organizational criteria.
• Provide clinical leadership in the Physician Review Units and participate in policy development.
• Participate in continuous quality improvement activities within the unit.
• Assist in the development of Physician Review Units' policies and procedures.
• Engage in the appeals process related to service denials.

Skills

Clinical judgment

Managed care understanding

PC proficiency

Clinical leadership

Education

MD/DO board-certified (ABMS)

Job description

Remote in any state except NY, CA, HI or AK

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.

Notes:

This position will work every weekend and possible holidays

Must be available M-F for full-time training to start

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status