Physician Reviewer

Job Overview

Remote in one of our plan states, 40 hours per week with weekend coverage in rotation. Pay should align with conversion salary.

• Evaluates clinical service requests made by an organization's members and providers, using clinical judgment in conjunction with the 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.
• 5 years clinical experience, including inpatient experience, or any combination of education/experience that provides an equivalent background.
• Must have understanding of managed care and demonstrate primary care proficiency, as file review will be done via computer in most cases.
• Position does not provide direct patient care or medical diagnosis.

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.