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.

(Note: Position does not provide direct patient care or medical diagnosis.)



Required Qualification:
Preferably Family Medicine, Internal Medicine, Rheumatology, Gastroenterology

Job Tags

Similar Jobs