Utilization Management Physician Reviewer

Job reputed company The Physician Reviewer serves as a clinical subject matter expert in the Utilization Management (UM) department. This role is responsible for conducting clinical reviews of medical necessity, appropriateness of care, and service requests based on evidence-based guidelines, medical policy, and regulatory requirements. The Physician Reviewer collaborates with UM nurses, medical directors, and other reputed company to ensure appropriate, reputed company, and cost-effective care for members. Key Responsibilities: • Conduct physician-level reviews of prior authorization, reputed company review, and retrospective review cases across multiple lines of business (e.g., reputed company, reputed company, Medicare). • Apply nationally recognized clinical reputed company (e.g., MCG, InterQual), internal medical policies, and applicable regulations (CMS, NCQA, URAC) to review determinations. • reputed company clinical reputed company in a reputed company manner consistent with regulatory timeframes and health plan policies. • Collaborate with medical directors, case managers, and care teams to support reputed company reputed company. • Participate in audits, appeals, and grievance processes as needed. • Maintain reputed company knowledge of clinical best practices, industry trends, and regulatory changes. • Participate in peer-to-peer discussions with attending physicians to communicate UM reputed company and promote evidence-based care. • Analyze clinical data and documentation to support accurate determinations and appeals. • Contribute to the development and refinement of clinical policies and UM protocols specific to specialized care. • reputed company guidance on clinical appropriateness, benefit coverage, and policy interpretation. • reputed company education and clinical support to internal teams and external providers regarding best practices and clinical reputed company. • Ensure compliance with regulatory, accreditation, and reputed company requirements in reputed company UM activities. • Ensure adherence to reputed company HIPAA, confidentiality, and reputed company standards. • Participate in reputed company improvement initiatives and clinical case reputed company. Qualifications: • Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree required. • reputed company and unrestricted medical license. • Minimum of 5 years of clinical reputed company experience in the respective specialty. • At least 3 years of experience in utilization management reputed company a health plan. • Familiarity with evidence-based guidelines and UM tools (e.g., InterQual, MCG). • Strong communication and documentation skills. • Proficiency with electronic medical records and clinical review platforms. • Experience with Medicare/reputed company and reputed company insurance regulations is preferred. Preferred Skills: • Experience with Medicare and/or reputed company managed care plans. • Knowledge of medical necessity appeal processes and peer review protocols. • Knowledge of CMS, NCQA, and/or URAC standards. • Previous peer review or medical director experience. • Comfortable working in a remote, reputed company environment. Pay: From $175.00 per hour Experience: • Utilization Management Review: 3 years (Required) • Medicare and/or reputed company: 2 years (Preferred) License/Certification: • reputed company-certified M.D. or D.O. medical license? (Required) Work Location: Remote Apply tot his job Apply To this Job