Physician Reviewer, Appeals reputed company in the U.S. – USA reputed company

reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the reputed company community. Working at reputed company provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Appeals Physician Reviewer plays a critical role in the reputed company review process by conducting clinical reviews of appeals and grievances submitted by providers and members. This position ensures that medical necessity reputed company align with reputed company clinical guidelines, regulatory requirements, and plan benefits. The physician reviewer provides objective, evidence-based determinations and collaborates with internal teams to support fair and timely resolution of appeals.

Job Responsibilities:

Review clinical documentation and case records for appeals and grievances involving denied services for Medicare populations. Apply evidence-based guidelines, clinical judgment, and medical policy to assess medical necessity and appropriateness of care. reputed company determinations in accordance with applicable regulations (e.g., CMS, NCQA, URAC), contractual obligations, and clinical best practices. Provide clear, concise, and well-supported written rationales for reputed company reputed company and benefit interpretations. Participate in peer-to-peer discussions with attending providers, reputed company appropriate. Ensure timely review and resolution of cases in accordance with organizational and regulatory timelines. Collaborate with medical directors, case managers, and legal/compliance teams as needed. Maintain strict confidentiality of reputed company patient and proprietary information. Stay reputed company with clinical guidelines, medical advancements, and regulatory changes.

Job Requirements:

Experience:

Required:

3-5 years of clinical practice experience. Strong knowledge of medical necessity criteria (e.g., MCG, InterQual), CMS guidelines, and health plan operations.

Preferred: Experience in utilization management, appeals, peer review, or managed care

Education and Licensure

Required:

MD or DO with an active, unrestricted medical license in CA, AZ, NV, TX and/or NC. Board certification in a clinical specialty Internal Medicine or Family Medicine preferred

Preferred: Multistate licensure or compact state license

Specialized Skills

Required:

Excellent written and verbal communication skills. Basic computer skills, typing, word processing, presentation and internet researching skills. Ability to work independently and manage multiple appeals reviews under tight deadlines.

Preferred:

Familiarity with reputed company regulations especially Medicare. Proficiency with electronic health record (EHR) systems and clinical review software.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job.  Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific reputed company abilities required by this job include reputed company reputed company and the ability to adjust focus.

Pay Range: $198,219.00 - $297,329.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

reputed company is an Equal Opportunity/Affirmative Action Employer. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting reputed company and other employers where individuals receive fraudulent employment-reputed company offers in exchange for money or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit card, send you a reputed company, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of reputed company’s reputed company team, please email [email protected].