Utilization Management Physician Reviewer (PA or NJ Licensed)

Position Responsibilities

• Conduct clinical review of prior authorization, concurrent review, and retrospective review requests to determine medical necessity and appropriateness of services.
• Collaborate with utilization management nurses and clinical staff to support timely decision-making.
• Review appeals and grievances related to medical necessity and participate in fair hearing processes as required.
• Ensure compliance with federal and state regulations, NCQA/URAC standards, and MCO policies.
• Serve as a liaison between the medical management department and providers, offering guidance on clinical criteria and utilization trends.
• Participate in interdisciplinary rounds and case review meetings as needed.
• Identify utilization trends and contribute to the development of policies, clinical criteria, and medical management strategies.
• Support quality improvement initiatives and population health programs as needed.

General

• Provide strategic direction for health plan market/product medical management and health service operational oversight, management, and performance.
• Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services.
• Deliver innovative, integrated solutions in support of client goals and engagements.
• Lead engagements ensuring completion of all contracted services.
• Present findings, recommendations, and plans to Client executives.
• Facilitate complicated problem-solving discussions to drive to timely, effective decision making.
• Advise and persuade key decision makers and influencers.
• Deliver concise, clear interpersonal communication to both internal and external audiences.
• Facilitate streamlined executive summaries, next step recommendations, and communication to all levels of Clearlink and client/partner organization(s).
• Articulate performance across multiple projects with qualitative and quantitative results/outcomes.
• Influence others to best course of action through advanced understanding of changing business landscapes.
• Develop strategies, goals, and plans in response to changing business conditions.
• Leverage best practice methodologies and approaches across individual account strategies/client plans.
• Establish short term KPIs and long-term goals and track progress to ensure achievement.
• Develop or update policies, procedures, and workflows as required to support business needs and requirements.
• Coach and mentor staff to reach established engagement goals, plan deliverables, and KPIs.
• Audit and adapt process, approach, plan, and/or activities in real time to mitigate risk and ensure critical path activities.
• Support account management relationships with key client decision makers.

Qualifications

• Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance.
• Ability to translate trends, innovation, operations, financing, costs, requirements, and performance into scalable activities and repeatable outcomes.
• New product/market strategy, design, and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid, and/or associated lines of business.
• New population strategy development including identification, program design, and implementation.
• Operationalizing requirements for complex memberships, ensuring outcome delivery.
• Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity.
• Ability to interpret and educate on complex concepts, requirements, and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
• Strategic leader with ability to produce, manage, and maintain system-wide change through influence and persuasion.
• Advanced knowledge of project management principles, methods, and techniques.
• Excellent communication skills both written and oral.
• High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred.
• Medical Degree (MD or DO) required; Must be actively licensed in Pennsylvania or New Jersey.
• Masters degree in Healthcare or Business Administration or related field Degree preferred.
• 10+ years administrative leadership achievement in health plan operations with progressive responsibility.
• CMO level experience preferred.
• 7+ years of experience in a government payor environment with expertise in medical management practice with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, Commercial etc).
• 5+ years delivering results, managing teams, and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.

Physical Requirements

• Must be able to sit in a chair for extended periods of time.
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word.
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices.
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse.
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types.
• Must be able to fluently communicate both verbally and in writing using the English language.
• Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations, and responsibilities simultaneously.

Time Zone

Eastern or Central

Other Information

Expected Hours of Work: Friday 8am – 5 pm; with ability to adjust to Client schedules as needed.

Travel: May be required, as needed by Client.

Direct Reports: None.

Salary Range: $100.00 - $150.00/hr.

EEO Statement: It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives, and regulations of Federal, state, and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.