Physician Reviewer

Description: Evaluates medical benefit medication service requests made by an organization's members and providers. Uses clinical judgment in conjunction with organization's criteria, national guidelines and standards, and evidence-based scientific literature to adjudicate these requests. May also provide clinical expertise to other areas of the organization. Participates in company and legally mandated processes to evaluate medical drug benefit service requests. Performs scheduled peer-to-peer conversations scheduled through company customer service line. Participates in the development of the Specialty Review Units' policies, processes, 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.)