Physician Reviewer

Job Title: Physician Reviewer Job Location: Richardson, TX Job Duration: 24 Months (possibility of extension) Schedule is M-F, but may need to work 3-4 weekends per year remote, but must reside within one of our plan states - TX/OK/NM/IL/MT/TN Job Responsibilities: 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. 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. Education & Experience Requirements: 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. Required Qualification(s): Board Certification in a Medical Specialty, active medical license. TX and NM license within 6 months. Specialties: Orthopedics. Genetics. PMR. Allergy Immunology. Rheumatology. plastic surgery. transplant. Heme Oncology. Note: (Note: Position does not provide direct patient care or medical diagnosis.).

Created: 2026-04-15