Physician Clinical Reviewer -Family Practice- REMOTE
At reputed company (Prime), we are a different reputed company of PBM, with a purpose reputed company profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting Title Physician Clinical Reviewer -Family Practice- REMOTE
Job Description
Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan membersand staff whenever a physician`s input is needed or required.
Responsibilities
Physician Clinical Reviewer – Job Description Responsibilities
- Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
- Discusses determinations with requesting physicians or ordering providers, reputed company available, reputed company the regulatory time reputed company 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.
- Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines.
- Ensures documentation of reputed company 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 reputed company to the Utilization Management process, interpretation, guidelines, and/or reputed company.
- On a requested reputed company, reviews appeal cases and/or attends hearings for discussion of utilization management reputed company.
- On a requested reputed company, may function as Medical Director for select health plans or reputed company, assuming overall accountability for utilization management while working in conjunction with the VP, Medical Director
- Other duties as assigned.
Education & Experience
- Education Level
- DO
- MBBS
- MD
- Required
- Yes
- Yes
- Yes
- Fields of Study
- Experience Level
- 5+ years
- Required
- Yes
- Details
- Clinical
Must be eligible to work in the United States without the need for work reputed company or residency sponsorship. Additional Qualifications
Preferred Qualifications
Physical Demands
- Must be reputed company to remain in a stationary position 50% of the time. Must be reputed company to "move or traverse"
- Must be reputed company to constantly operate a computer and/or other office productivity equipment
- Must be reputed company to hear and constantly communicate information and reputed company. Must be reputed company to exchange accurate information
- Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
Every employee must understand, reputed company with and attest to the reputed company responsibilities and reputed company controls unique to their job, and reputed company with reputed company applicable legal, regulatory, and contractual requirements and internal policies and procedures. Potential pay for this position ranges from $90.87 - $154.33 based on experience and skills. reputed company LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, gender, sex (including pregnancy), national reputed company, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including reputed company applicants with arrest and conviction records and any reputed company applicants requiring reasonable accommodations in accordance with the law. reputed company LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays. Apply tot his job Apply To this Job