Physician Clinical Reviewer – Psychiatry

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate cases where clinical decisions cannot be made by Initial Clinical Reviewers.

• Communicate determinations with requesting physicians or ordering providers via phone or fax within regulatory deadlines.

• Offer clinical justification for both standard and expedited appeals.

• Support and serve as a resource for Initial Clinical Reviewers.

• Implement medical/clinical review guidelines and parameters to ensure uniformity, proper utilization, and adherence to Prime policies, URAC, and NCQA standards.

• Accurately and promptly document interactions with medical office staff and physicians/providers.

• Engage in ongoing inter-rater reliability training and assessments.

• Assist Medical Directors with utilization management research inquiries and activities.

• Review appeal cases and/or participate in hearings when necessary.

• May act as Medical Director for specific health plans or regions upon request.

• Carry out additional assigned responsibilities.

⛳️ Requirements

• Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or an international MBBS degree with successful completion of a U.S.-based internship and residency is required.

• Successful completion of a U.S.-based fellowship is necessary for subspecialists.

• Current, unrestricted medical license to practice in one or more states in the United States is required.

• Board certification from ABMS, ABOS, ABIM, or ABOIM.

• At least 1 year of experience in clinical review.

• Must be eligible to work in the United States without the need for work visa or residency sponsorship.

• Familiarity with utilization management principles and procedures within managed care organizations.

• Preferred: Experience with Medicare Part D.

• Preferred: Background in cost-benefit analysis, quality assurance, and continuous quality improvement.

• Must adhere to job-specific security responsibilities, controls, legal, regulatory, contractual, and internal policy requirements.

• Ability to perform essential job functions; reasonable accommodations are available upon request.

🏝️ Benefits

• Benefits, incentives, and additional compensation are available; the posting directs applicants to Prime's Benefits Page for further details.

• An equal opportunity and affirmative action employer.

• Reasonable accommodations for applicants with disabilities.

• Tobacco-Free Workplace.