Medical Review Specialist

2 weeks ago


Chicago, Illinois, United States w3r Consulting Full time
Job Summary

We are seeking a highly skilled Medical Review Specialist to join our team at w3r Consulting. As a key member of our team, you will play a critical role in evaluating medical benefit medication service requests made by our organization's members and providers.

Key Responsibilities
  • Evaluate medical benefit medication service requests using clinical judgment and in conjunction with our organization's criteria, national guidelines, and standards.
  • Utilize evidence-based scientific literature to adjudicate requests and provide clinical expertise to other areas of the organization.
  • Participate in company and legally mandated processes to evaluate medical drug benefit service requests.
  • Engage in scheduled peer-to-peer conversations with members and providers through our customer service line.
  • Contribute to the development of our Specialty Review Units' policies, processes, and procedures.
  • Participate in unit continuous quality improvement activities.
Requirements
  • Board Certified (ABMS) M.D. or D.O. with an unrestricted and active license to practice medicine.
  • At least 5 years of clinical experience, including inpatient experience.
  • Strong understanding of managed care and proficiency in PC software.

Please note that this position does not provide direct patient care or medical diagnosis.



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