Remote Physician Reviewer - Fraud, Waste & Abuse (FWA)

Remote Physician Reviewer - Fraud, Waste & Abuse (FWA)

(must reside in Pennsylvania, New Jersey or Delaware)

We're seeking a Physician to support high-impact medical review activities across Fraud, Waste & Abuse (FWA), utilization management, and complex claims.

Responsibilities:

• Review complex utilization management and appeals cases requiring senior clinical judgment
• Perform FWA medical reviews for large self-funded and union-sponsored health plans
• Evaluate medical necessity, causality, and appropriateness of care for no-fault and commercial claims
• Apply evidence-based guidelines to balance quality, safety, and cost containment
• Conduct physician-to-physician discussions and deliver clear, defensible clinical decisions

Required Experience:

• MD or DO with active license
• Experience in utilization management, peer review, or FWA investigations
• Strong clinical judgment and ability to communicate complex decisions clearly