Physician Reviewer

w3r Consulting; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

Join a forward-thinking company as a Clinical Evaluator in a remote role focused on clinical service requests. This position requires a Board Certified M.D. or D.O. with extensive clinical experience. You will leverage your clinical judgment to review and approve services, ensuring compliance with medical guidelines. Engage in quality improvement initiatives while working collaboratively with case managers to identify high-risk members. This role offers a competitive pay rate and the opportunity to make a significant impact in the healthcare industry without direct patient care responsibilities.

Qualifications

• Board Certified M.D. or D.O. with 5+ years of clinical experience.
• Understanding of managed care and proficiency in file review.

Responsibilities

• Review clinical service requests ensuring medical necessity.
• Collaborate with case management to develop care plans.

Skills

Clinical Judgment

Problem Solving

Policy Development

Quality Improvement

Education

Board Certified M.D. or D.O.

5+ years of clinical experience

Tools

Electronic Medical Records (EMR) Systems

PC-based File Review

Job description

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This range is provided by w3r Consulting. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$105.00/hr - $105.00/hr

Direct message the job poster from w3r Consulting

If you are interested, please forward your current resume to [e-mail] and you can also reach me at 925-326-2471 to discuss your career aspirations.

Location: Remote

Duration: 24 Months Contract

Pay Rate: $105.00/hour on W2

Note: This position will be Saturday and Sunday, 9a-6p & position does not provide direct patient care or medical diagnosis.

Job Description

Evaluates clinical service requests made by an organization's members and providers, using clinical judgment and organizational criteria.

• Provides clinical leadership and identifies opportunities for managing members' clinical situations with creative problem solving and future planning.
• Participates in evaluating clinical service requests and the appeal process for service denials.
• Practices anticipatory case management in partnership with case managers.
• Contributes to policy and procedure development, and participates in quality improvement activities.
• Performs other duties as assigned by the Medical Director.

Required Qualifications

Board Certified (ABMS) M.D. or D.O., unrestricted license, with at least 5 years of clinical experience including inpatient care, or equivalent education/experience.

• Understanding of managed care and proficiency with PC-based file review; note that this position does not involve direct patient care or diagnosis.

Day-to-Day Responsibilities

• Review clinical service requests ensuring medical necessity and guideline compliance.
• Use clinical judgment with evidence-based criteria and guidelines to approve, modify, or deny services.
• Participate in the appeals process, providing clinical rationale and documentation.
• Collaborate with case management to identify high-risk members and develop care plans.
• Contribute to policy development and quality improvement initiatives.
• Utilize electronic review tools and EMR systems for documentation and review.
• This role involves no direct patient care, focusing solely on chart/file review and decision-making based on clinical and regulatory criteria.

Additional Information

Position level: Mid-Senior level

Employment type: Full-time

Job function: Education and Healthcare Provider

Industry: Insurance