Physician Reviewer

Job Title: Physician ReviewerJob SummaryThe Physician Reviewer is responsible for evaluating clinical service requests submitted by members and providers, utilizing medical expertise and established organizational criteria to make determinations. This role supports utilization management processes, contributes to policy development, and participates in appeals and quality improvement initiatives. This is a non-patient-facing position with no direct clinical care or diagnosis responsibilities.Schedule & CompensationHours: 20–40 hours per weekSchedule: Flexible, with potential weekend rotation coveragePay Rate: $105 – $115/hourWork Arrangement: Fully remote (Not available in CA, NY, HI, or AK)Key ResponsibilitiesReview and evaluate clinical service requests to determine medical necessity based on established guidelinesApply clinical judgment in conjunction with organizational criteria to approve, modify, or deny requestsParticipate in the Physician Review Unit (PRU) appeal process for service denialsProvide clinical insight and leadership to support utilization management activitiesIdentify opportunities for proactive and creative management of members’ clinical situationsContribute to the development and enhancement of clinical policies and proceduresSupport continuous quality improvement (CQI) initiatives within the review unitCollaborate with internal teams and Medical Director to ensure consistent and compliant decision-makingPerform additional duties as assignedQualificationsEducation:Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.)Certifications & Licensure:Board Certified through ABMSActive, unrestricted medical license requiredPreferred: Licensure in New Mexico (NM) and/or Oklahoma (OK)Experience:Minimum 5 years of clinical experience, including inpatient carePrior utilization management or peer review experience preferredExperience in managed care strongly preferredTechnical SkillsStrong understanding of managed care principles and utilization review processesProficiency with computers and clinical systems; ability to perform reviews electronicallyFamiliarity with evidence-based guidelines and medical necessity criteria#INDEPI