Job Description
Can work remotely in any state except CA, NY, HI or AK
20 - 40 hours/week and possible weekend coverage (in a rotation)
Summary:
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.
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. ...