Physician Reviewer

Job description

Overview We are seeking a high-performing Physician Reviewer to join our Group Health division. The role is responsible for delivering timely, defensible utilization review determinations across a high-volume, fast-paced environment. Reviews span multiple case types, including preauthorization, appeals, DRG clinical validation, benefit review, and experimental/investigational determinations. Key Responsibilities: Perform utilization review for: - Preauthorization requests - Appeals (first and second level) - Independent external reviews - DRG validation and clinical review - Benefit and coverage determinations - Experimental/Investigational (E/I) review Apply evidence-based criteria and guidelines, including: - InterQual - MCG - CMS guidelines (including 2-Midnight Rule) - LCD/NCD - Client-specific policies - Produce clear, concise, and defensible clinical rationales - Maintain high accuracy and consistency across determinations - Meet or exceed turnaround time (TAT) expectations, including urgent cases - Participate in peer-to-peer discussions as needed - Collaborate with QA and operational teams to ensure quality and compliance - Reviews may be conducted within internal systems o...