Physician Medical Reviewer - REMOTE
Physician Medical Reviewer - REMOTE
Posted on :
08-04-2025
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1 Vacancy
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Job Description
We are currently hiring aParttime REMOTE Physician Medical Reviewer! If you possess strong clinical expertise exceptional attention to detail excellent analytical and critical thinking skills hold an unrestricted Oregon medical license and are passionate about contributing to a team that makes a meaningful impact you could be the ideal candidate for this position!!Apply today!
JOB SPECIFICATIONS
Classification:NONEXEMPT Status:PARTTIME 20HOURS/WEEK Business Operations are Monday Friday generally 8am to 5pm Pacific Time
Salary:$155 $165/HOURLY
Department:Administration Work Location:REMOTE (OR CA AZ CO TX AL MO FL)
Reports to:Chief Medical Officer
Supervision Exercised:Nonsupervisory
Job Purpose: Medical Reviewer
This position is a vital member of the utilization management team and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. This position interacts with physicians leadership and management staff other Physician Clinical Reviewers (PCR) and the utilization management team to support effective medical determination.
Qualifications Education & Experience
- Current unrestricted State of Oregon medical license. Have graduated from an accredited medical school board certified preferably in one of the primary care specialties
- Preference given for candidate with three to five 5 years of experience conducting medical review preferably in a managed care setting
Essential Responsibilities: Medical Reviewer
- Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer
- Discusses determinations with requesting physicians or ordering providers when available within the regulatory timeframe of the request by phone or fax
- Provides clinical rationale for standard and expedited appeals
- Aids and acts as a resource to initial reviewers as needed to discuss cases
- Utilizes clinical review guidelines and parameters to assure consistency in the MD review process to ensure appropriate utilization and compliance with company policies and procedures and OHA guidelines
- Ensures documentation of all communications with medical office staff or MD provider is recorded in a timely and accurate manner
- Participates in ongoing training per interrater reliability process
- Conducts and document peertopeer physician consultations as requested and required
- Reviews medical information trends experiences and approaches and assists in the development of strategic plans for clinical improvements
- Ensures compliance with regulatory and accreditation requirements
- Analyzes and remain current on national state and local regulations and legislation which impacts the health care profession
- Assists the Chief Medical Officer in research activities related to the Utilization Management process interpretation guidelines and/or system support
- Provides clinical expertise with respect to planning and establishing goals and policies to improve clinical operations
- Represents the organization through state appeal processes reviewing appeal cases and attending hearings for discussion of utilization management decisions
- On a requested basis may function as Medical Officer assuming overall accountability for utilization management while working in conjunction with the Chief Medical Officer
- Participate in quality and organizational process improvement activities and teams when requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Other duties as assigned
Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER
- Participate in quality and organizational process improvement activities when requested
- Support and contribute to effective safety quality and risk management efforts by adhering to established policies and procedures maintaining a safe environment promoting accident prevention and identifying and reporting potential liabilities
- Openly clearly and respectfully share and receive information opinions concerns and feedback in a supportive manner
- Work collaboratively by mentoring new and existing coworkers building bridges and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers which includes team members members students visitors and vendors by consistently exceeding the customers expectations
- Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
Knowledge Skills & Abilities:
- Knowledge of healthrelated quality improvement concepts principles and practices
- Knowledge of managed care concepts principles and operations
- Knowledge of disease management principles and practices
- Knowledge of PatientCentered Medical Home concepts principles and practices
- Knowledge of evidencebased practices and requirements to evaluate existing standards and implement new procedures
- Understanding of principles of health care of populations
- Knowledge of OHP program requirements benefit package eligibility categories and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
- Knowledge of the Oregon Health Authorities Coordinated Care Organization required metrics
- Critical attention to detail for accuracy and timeliness
- High degree of initiative judgment discretion and decisionmaking
- Ability to exercise sound clinical judgment independent analysis critical thinking skills and knowledge of health conditions to determine best outcomes for members
- Ability to report to work as scheduled and willingness to work a flexible schedule when needed
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy Poverty Informed Systemic Oppression language access and the use of healthcare interpreters uses of data to drive health equity Cultural Awareness TraumaInformed Care Adverse Childhood Experiences (ACEs) Culturally and Linguistically Appropriate Service (CLAS) Standards and universal access
- Knowledge and understanding of how the positions responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA HIPAA Waste Fraud and Abuse
- Awareness and understanding of equity diversity inclusion and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social political and environmental contexts of policies programs and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions conclusions or approaches to problems
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations human needs and aware of how ones actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
Working Conditions:
This position must have the ability to remain in a stationary position occasionally move about inside the office to access office machinery printer etc. frequently communicate and exchange accurate information.
Work Condition: remote work
Employee generally works within a remote work from home environment.
Travel may be required on occasion.
Hours of operations and specific staff scheduling may vary based on operational need.
Exposed to:
Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
Machines equipment tools and supplies used:Constantly operates a computer or other office productivity machinery or software such as fax copier calculator multiline telephone system or scanner.
May answer a high volume of telephone calls complete documentation and use computer programs to either obtain or record information.
Multiple Duties:Must be able to work under conditions of frequent interruption and be able to stay on task.
Other Information:
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities duties or responsibilities that are required of DOCS Management Services employees. Other duties responsibilities and activities may change or be assigned at any time with or without notice.
Employment Type
Full Time
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