Utilization Management Physician Reviewer

The company the company, a certified “Great Place to Work” company is seeking a Physician to provide utilization review services for the Group Health Department.

This role requires utilizing clinical expertise to review medical records and provide an interpretation of the medical appropriateness of services in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.

The company the company’s success relies on individual and team contributions every day. We care for our customers, each other, and the company the company

MAJOR DUTIES & RESPONSIBILITIES

• Review requests for Prior Authorizations and Appeals including medical records and make a medical necessity determination in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.

• Ensure clear, concise, and well-supported rationales for determinations.

• Make mandated phone calls.

• Provide responses in member friendly language using provided templates.

• Return cases on or before the due date and time.

• Assist with quality assurance of reports prior to submission to clients.

• Maintain proper credentialing, state licenses, and any special certifications

• Utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature for decision-making.

• Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.

• Provide copies of any criteria utilized in a review with the report.

• Other duties & special projects, as assigned and based on business needs.

EDUCATION/CREDENTIALS

• Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US.

JOB RELEVANT EXPERIENCE

• Minimum five years of postgraduate experience

• Extensive clinical business background required

• Experience in Utilization Management with criteria review utilizing standard practice guidelines

• Medicaid/Medicare experience preferred

JOB RELATED SKILLS/COMPETENCIES

• Working knowledge of URAC and relevant State and Federal compliance guidelines.

• Excellent communication skills.

• High-level understanding of medical insurance and utilization management.

• Critical thinking

• Ability to manage time efficiently and meet specific deadlines

• Computer literacy and typing skills required

Benefits

We offer generous Paid Time Off, an excellent benefits package, and a competitive salary. If you want to work in an exciting, fast-paced environment where you can provide meaningful contributions, then we encourage you to apply.