What are the responsibilities and job description for the Physician Reviewer position at elevancehealth?
Job ID: JP00046404
Anticipated Start Date: April 1, 2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Responsible for providing day-to-day guidance, support, and leadership for clinical and/or quality activities under the guidance of a Medical Director. May be responsible for supporting one or more Medical Directors in ensuring clinical integrity of broad and significant clinical programs. May perform clinical review.
Primary duties may include, but are not limited to:
Supports clinicians to ensure timely and consistent responses to members and providers.
Conducts peer-to-peer clinical reviews with attending physicians or other ordering providers to discuss review determinations, and patients' office visits with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
May participate in a physician on-call rotation for a 24x7 unit.
May assist in the practitioner appeal reviews, appropriateness criteria reviews, medical technology assessments, setting and implementing QI initiatives, and practitioner/provider credentialing.
Under direction, may be responsible for the administration of medical services for company health plans including medical policies.
Serves as a resource and consultant to other areas of the company.
May interpret existing medical policy.
May be required to represent the company to external entities and/or serve on internal and/or external committees.
This level typically is more of a supportive position with oversight from a Medical Director.
May be responsible for a portion of a clinical program and/or performing clinical reviews. Is more involved in supporting one or more Medical Directors, as well as the programs to which the Medical Director is assigned.
May manage pieces of programs, but would not have the full scope of program management expected of the Medical Director.
Receives guidance and oversight from a Medical Director who is an individual contributor in addition to direction received from immediate manager.}
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Requirements:
Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
Must possess an active unrestricted medical license to practice medicine or a health profession. Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US. Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. {Note: The following are level distinctions not required for posting.
Requires 3 years of clinical experience in inpatient or post-acute care
1 year of experience conducting medical-necessity clinical case reviews
Demonstrated ability to apply clinical criteria/policies and communicate decisions effectively with providers and internal teams
Strong documentation skills and ability to work within turnaround-time requirements
Job Type: Possible Contract to hire
Additional Details:
Preferred Qualifications
Prior experience in Utilization Management (UM), health plan medical management, or managed care
Experience with post-acute settings (SNF, IRF, LTACH, home health) and transitions of care
Familiarity with standard clinical criteria/tools (e.g.MCG)
Work Schedule: Monday–Friday between the hours of 8AM - 8PM CST (option for weekend work (as available/needed; scheduling to be determined)
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.
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This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.