Physician Clinical Reviewer – Endocrinology
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Job Description
Physician Clinical Reviewer responsible for medical review of service requests in utilization management. Collaborating with physicians and health plan members to ensure compliance with guidelines.
Responsibilities:
- Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
- Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax.
- Provides clinical rationale for standard and expedited appeals.
- Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
- Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
- Participates in on-going inter-rater reliability training and testing
- Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support.
Requirements:
- Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO) or international degree with successful completion of United States based internship and residency
- Current, unrestricted license to practice medicine in one or more states of the United States
- Board Certified by American Board of Medical Specialties (ABMS), American Board of Osteopathic Specialties (ABOS), American Board of Internal Medicine or American Board of Osteopathic Internal Medicine (ABIM/ABOIM)
- 1 year of work experience in clinical review
- Must be eligible to work in the United States without the need for work visa or residency sponsorship.
Benefits:
- Health insurance
- Health and wellness programs
- Paid time off
- Professional development opportunities
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