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Title: Physician Reviewer / Medical Director
Location: Texas, United States (Remote)
Summary
Evaluates clinical service requests using clinical judgment and organizational criteria, participates in appeals and quality improvement activities, and provides clinical leadership and anticipatory case management in a managed care environment. This remote role does not involve direct patient care or medical diagnosis.
Added on: 08/07/2025
Full Job Description
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.
Notes:
Remote position
M-F
Position does not provide direct patient care or medical diagnosis.
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