Job Description

Job Description

Job Description

Client: Health Insurance/Managed Care Organization

REMOTE but must be near Nashville, TN

M-F 40 hours per week

Description:

• 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.
• Participates 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.

Required Qualification(s): (No Value)

• 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.

W3R Consulting is a Southfield, Michigan based staffing and consulting firm that provides talent, technology consulting and advanced analytics solutions to Fortune 500 companies in the automotive, financial, healthcare, insurance, professional and business services, and retail industries. In 2012, w3r acquired Nurse Now Staffing. inner of numerous customer and industry awards, this year W3R celebrates 22 years of innovation, exceptional customer service and community engagement.

Company Description

W3R Consulting is a Southfield, Michigan based staffing and consulting firm that provides talent, technology consulting and advanced analytics solutions to Fortune 500 companies in the automotive, financial, healthcare, insurance, professional and business services, and retail industries. In 2012, w3r acquired Nurse Now Staffing. inner of numerous customer and industry awards, this year W3R celebrates 22 years of innovation, exceptional customer service and community engagement.

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