Remote Physician Reviewer - Fraud, Waste & Abuse (FWA)
Occupations:
Physicians, All OtherFamily Medicine PhysiciansGeneral Internal Medicine PhysiciansHealthcare Diagnosing or Treating Practitioners, All OtherPhysician AssistantsIndustries:
Offices of PhysiciansAdministration of Environmental Quality ProgramsRestaurants and Other Eating PlacesSpecial Food ServicesPsychiatric and Substance Abuse HospitalsRemote Physician Reviewer - Fraud, Waste & Abuse (FWA)(must reside in Pennsylvania, New Jersey or Delaware)We're seeking a Physician to support high-impact medical review activities across Fraud, Waste & Abuse (FWA), utilization management, and complex claims.Responsibilities:Review complex utilization management and appeals cases requiring senior clinical judgmentPerform FWA medical reviews for large self-funded and union-sponsored health plansEvaluate medical necessity, causality, and appropriateness of care for no-fault and commercial claimsApply evidence-based guidelines to balance quality, safety, and cost containmentConduct physician-to-physician discussions and deliver clear, defensible clinical decisionsRequired Experience:MD or DO with active licenseExperience in utilization management, peer review, or FWA investigationsStrong clinical judgment and ability to communicate complex decisions clearly