Physician ED Claims Reviewer

About the Role

A Physician with an active US license is needed to conduct clinical reviews of claims and utilization management (UM) authorization requests for clinical necessity.

Responsibilities

• Review claims and UM authorization requests for clinical necessity.
• Apply medical coding (CPT/HCPCS) and managed care knowledge in decision-making.
• Work proficiently across various systems and applications.

Requirements

• Active US medical license.
• Minimum of 3–5 years of recent (last 2–3 years) clinical experience in emergency department medicine (internal medicine experience will be considered).
• Experience in managed care and clinical UM case reviews.
• Knowledge of claims and medical coding (CPT/HCPCS codes).

Skills

• Experience or knowledge in utilization management (desired).
• Ability to work independently in a fast-paced environment.
• Strong Agile experience, including user story development, requirements gathering, and portfolio management.