Utilization Management Physician Reviewer

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

📋 Description

• Evaluate requests for Prior Authorizations and Appeals, including medical documentation, and make determinations regarding medical necessity in accordance with state regulations, nationally accepted evidence-based guidelines, and client-specific policies.

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

• Conduct required phone calls.

• Provide responses in a member-friendly manner using designated templates.

• Return cases by the specified due date and time.

• Assist in the quality assurance process of reports before they are submitted to clients.

• Maintain appropriate credentialing, state licenses, and any necessary special certifications.

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

• Identify and address quality assurance issues, complaints, regulatory matters, depositions, court appearances, or audits.

• Include copies of any criteria used in a review with the report.

• Undertake other duties and special projects as assigned based on business requirements.

⛳️ Requirements

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

• Minimum of five years of postgraduate experience.

• A strong clinical business background is required.

• Experience in Utilization Management with criteria review according to standard practice guidelines.

• Medicaid/Medicare experience is preferred.

• Familiarity with URAC and applicable State and Federal compliance guidelines.

• Excellent communication abilities.

• Comprehensive understanding of medical insurance and utilization management.

• Strong critical thinking skills.

• Ability to effectively manage time and meet specific deadlines.

• Proficient computer skills and typing abilities are required.

🏝️ Benefits

• We provide generous Paid Time Off.

• An outstanding benefits package.

• A competitive salary.