Physician Reviewer

Solving IT; United States; On-site; USD 120,000 - 170,000; Full time

Benefits offered by this job

Five diverse health plan options

PPO dental plan

Term Life/AD&D Insurance

401(k) Savings Plan

Health/dental premium coverage

Job summary

A healthcare management organization is seeking experienced Physician Reviewers to join their Medicare Utilization Management team in a remote position. Responsibilities include reviewing clinical service requests, applying evidence-based guidelines, and collaborating to ensure quality care for members. Candidates must be board-certified physicians with a minimum of 5 years of clinical experience. A comprehensive benefits package including health plans and 401(k) is offered, promoting equality and diversity in the workplace.

Qualifications

• 5+ years of post-residency clinical experience, including inpatient care.
• Understanding of managed care principles.
• Internal Medicine specialization preferred.
• Understanding of managed care principles.
• Proficiency with computer-based case review systems.

Responsibilities

• Review clinical service requests using clinical judgment.
• Identify opportunities to proactively manage members’ clinical situations.
• Conduct peer-to-peer discussions with treating physicians as needed.
• Participate in the Physician Review Unit’s appeals process for service denials.
• Contribute to the development and refinement of unit policies and procedures.
• Support continuous quality improvement initiatives within the team.
• Conduct peer-to-peer discussions with treating physicians and other providers as needed.
• Manage an average of 35–40 cases per day, including inpatient reviews, precertification, and prior authorizations, using the MHK utilization management platform.

Skills

Board Certification (ABMS)

Strong communication skills

Teamwork skills

Proficiency with computer-based case review systems

Case review systems

Education

M.D. or D.O. with active medical license

Tools

MHK utilization management platform

Job description

Get AI-powered advice on this job and more exclusive features.

Location: Remote (Must reside in IL, MT, NM, OK, TN, or TX)

Position Overview

Our client is seeking experienced, board-certified physicians to join their Medicare Utilization Management team as Physician Reviewers. In this remote role, you will review clinical service requests, apply evidence-based guidelines, and collaborate with internal teams to ensure quality and cost-effective care for our members. This position does not involve direct patient care or medical diagnosis.

Key Responsibilities

• Review and adjudicate clinical service requests from members and providers using clinical judgment and organizational criteria.
• Identify opportunities to proactively manage members’ clinical situations and anticipate future healthcare needs.
• Partner with case managers on anticipatory case management strategies.
• Participate in the Physician Review Unit’s appeals process for service denials.
• Contribute to the development and refinement of unit policies and procedures.
• Support continuous quality improvement initiatives within the team.
• Conduct peer-to-peer discussions with treating physicians and other providers as needed.
• Manage an average of 35–40 cases per day, including inpatient reviews, precertification, and prior authorizations, using the MHK utilization management platform.

Qualifications

Required

• M.D. or D.O. with active, unrestricted medical license (any U.S. state).
• Board Certification (ABMS).
• Minimum of 5 years of post-residency clinical experience, including inpatient care.
• Understanding of managed care principles.
• Proficiency with computer-based case review systems.

Preferred

• Internal Medicine specialization (other specialties such as Ob/Gyn, Surgery, or Geriatrics will be considered).
• Technologically savvy with strong communication and teamwork skills.
• Team Size: 25 PR's + utilization management team.
• Workload: Generalist model, no specialty-specific caseload.
• Technology: AI-assisted case distribution for balanced workload.
• Onboarding: 6-week training program; 3-month total onboarding process.
• Weekend Coverage: 3–4 days per year on a rotating basis (Saturday or Sunday).
• Geographic Hiring Limitations: IL, MT, NM, OK, TN, TX.

Solving IT, a Woman and LGBTQ+ owned and operated organization, is thrilled to provide a comprehensive benefit package to all our W2 employees and their families, regardless of gender. We are proud to offer five diverse health plan options as well as a PPO dental plan through Blue Cross Blue Shield, Term Life/AD&D Insurance, and a 401(k) Savings Plan. Solving IT covers a portion of the health and dental premiums for our employees.

We champion equality and embrace diversity in all its forms. Creating an atmosphere that encourages varied perspectives to collaborate fosters personal development, strengthens team unity, and contributes to the overall success of the organization!

We actively encourage applications from all backgrounds and are committed to supporting your career advancement with the most up-to-date market insights and compensation data.

Seniority level: Associate

Employment type: Full-time

Job function: Health Care Provider