About the job

Physician Reviewer ---UTILIZATION REVIEW

Location: Dallas, TX--100% REMOTE

2 years+ years contract

M-F- 40 hours a week-Central time

.....As long as they have a medical license in any of the 50 states, that will get them started. But the expectation upon hiring is that they would immediately work toward getting a TX full medical license and a NM telemedicine medical license....

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.)

updated information:...PLEASE READ

.As long as they have a medical license in any of the 50 states, that will get them started. But the expectation upon hiring is that they would immediately work toward getting a TX full medical license and a NM telemedicine medical license.

.The position is in Appeals. The reviews will be of same or similar specialty subject matter. The UM reviews/medical necessity reviews are for level of care as well as procedures.

Also, depending on the specialty, they may also review for medications that relate to their field of expertise.

Preferred Qualification(s)...NICE TO HAVE

Orthopedics, Genetics, PMR, Allergy Immunology, Rheumatology, plastic surgery, transplant, HemeOnc

Innovative Systems Group

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Physician Reviewer