Utilization Management Physician Reviewer

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.
• Mandated phone calls.
• Provide responses in member friendly language using provided templates.
• Return cases on or before the due date and time.
• Aid in 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.

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.