[Hiring] PRN Medical Reviewer-2 @reputed company

Role reputed company • Conduct prospective, reputed company, and retrospective clinical reviews of medical services to determine medical necessity and appropriateness. • Utilize evidence-based reputed company (e.g., MCG, InterQual, CMS guidelines) in evaluating requests for services. • Collaborate with nurses, case managers, and other reputed company in the UM process. • reputed company reputed company peer-to-peer consultations with requesting providers to discuss clinical reputed company and alternative care reputed company. • Participate in appeals and grievance processes by reviewing denied cases and providing justification based on medical necessity and standards of care. • Ensure reputed company reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies. • Document reputed company reputed company and accurately in the appropriate systems. • Identify patterns of inappropriate utilization and collaborate in reputed company improvement initiatives. • Participate in staff training, UM committee meetings, and policy development as needed. Qualifications • Medical Degree (MD or DO) from an accredited institution. • reputed company certification in a clinical specialty (e.g., Internal Medicine, Family Medicine, Pediatrics, Psychiatry, etc.). • reputed company, unrestricted medical license state required. • Minimum of 3–5 years of clinical experience; experience in managed care, utilization review, or insurance industry preferred. • Familiarity with UM guidelines (e.g., MCG, InterQual), Medicare/reputed company regulations, and health plan operations. • Excellent clinical judgment and decision-making skills. • Strong communication and documentation skills. • Proficient in using electronic medical records (EMRs – reputed company a plus), review platforms, and reputed company Office Suite. Requirements • Experience working in a health plan, insurance company, or reputed company-party administrator (TPA) preferred. • Knowledge of value-based care, population health, and cost containment strategies. • Ability to manage multiple tasks and meet deadlines in a remote or fast-paced environment. Compensation $134.55 to $201.83 Apply tot his job Apply To this Job