Job Description

We're Hiring: Physician Reviewer!

We are seeking an experienced and detail-oriented Physician Reviewer to evaluate medical cases, ensure clinical accuracy, and support quality healthcare delivery.

Location: Nashville, United States
Work Mode: On-site
Role: Physician Reviewer

Job Description:

• Evaluates clinical service requests made by an organization's members and providers. Uses 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 Unit’s appeal process of service denials.
• Participates in the development of Physician Review Unit’s policies and procedures. Actively participates in all unit continuous quality improvement activities.
• Other duties as assigned by the Medical Director.

Qualifications:

• Board Certified (ABMS) M.D. or D.O., unrestricted and active license to practice medicine required, and 5 years clinical experience , including 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.

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