Utilization Management Physician Reviewer (PA)

Job Description

Job Description

We are seeking a highly qualified and experienced Physician with expertise in Utilization Management (UM) Review to join our team. In this role, you will combine your clinical knowledge with your understanding of healthcare utilization to ensure that medical services are being provided in a cost-effective, efficient and medically necessary manner. You will be responsible for reviewing medical cases, analyzing treatment plans and ensuring that care aligns with clinical guidelines, medical necessity and quality standards.

Board-certified M.D. or D.O. with an active and unrestricted medical license in Pennsylvania.

Duties and Responsibilities

· Evaluate clinical service requests made by an organization's members and providers for medical necessity.

· Participate in the physician review for peer-to-peer reviews and in the appeal process of service denials.

· May provide clinical leadership in other areas of the organization. Identifies opportunities to manage members' clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member.

· Participate in the process to evaluate clinical service requests.

· May aid with case management activities.

· Participate in continuous quality improvement activities.

· May participate in the development of physician review policies and procedures.

· Other duties as assigned by the client.

Note: Position does not provide direct patient care or medical diagnosis.

Skills and Qualifications

· Board-certified M.D. or D.O. with an active and unrestricted medical license in Pennsylvania.

· 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background.

· A minimum of 3 years of experience in Utilization Management.

· Experience working with various insurance providers, clinical decision support tools and review criteria.

· Demonstrate PC proficiency as file review will be done via computer and on various client platforms.

· Experience in medical documentation and data collection.

· Strong patient assessment skills.

· Knowledge of HIPAA regulations.