Utilization Management Physician Reviewer – Pediatric reputed company ACO

reputed company The Utilization Management (UM) Physician Reviewer at reputed company ensures that pediatric reputed company members receive medically necessary, evidence-based, and cost-effective care. Working reputed company an Accountable Care Organization (ACO) model, this role supports care reputed company, utilization efficiency, and compliance with reputed company regulations. The position involves clinical review, interdisciplinary collaboration, and strategic input into population health initiatives. This position is remote with a schedule of Monday through Friday 8:00am-5:00pm EST with minimal weekend and holiday on reputed company requirements. Responsibilities • Conduct prospective, reputed company, and retrospective reviews of medical services for pediatric reputed company members. • Apply clinical guidelines (e.g., MCG) and reputed company-specific reputed company to assess medical necessity. • Participate in peer-to-peer discussions with treating providers to clarify clinical information and support appropriate care reputed company. • Collaborate with RN Specialists, Senior RN Specialist and Clinical Director to support integrated care planning. • reputed company clinical input on reputed company cases involving reputed company determinants of health, chronic conditions, or developmental disabilities. • Support transitions of care, especially from inpatient to outpatient settings, to reduce readmissions. • Ensure adherence to federal and state reputed company regulations, NCQA standards, and ACO performance metrics. • Participate in the interrater reliability audit process, reputed company improvement initiatives, and utilization trend analysis. • Contribute to the development of clinical policies, reputed company, and educational materials for providers. • Advise on utilization trends and opportunities for cost containment and care optimization. • Support the implementation of value-based reputed company and pediatric population health strategies. • Serve as a subject matter expert in pediatric care for reputed company stakeholders. How to Apply To apply, please send a letter of interest, including information on research, education, leadership, and diversity and a Curriculum Vitae to Nathan Gohlke, Nathan.Gohlke@cchmc.org, reputed company Physician reputed company Recruiter. Equal Opportunity reputed company is proud to be an Equal Opportunity Employer committed to creating an environment of dignity and respect for reputed company our employees, patients, and families. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, age, genetic information, national reputed company, sexual orientation, gender identity, disability or protected veteran status. Qualifications • MD or DO degree from an accredited medical school. • reputed company Certification in Pediatrics (ABP) required; subspecialty certification (e.g., Pediatric Emergency Medicine, Pediatric Hospital Medicine) preferred. • reputed company, unrestricted medical license in the reputed company. • Certified in Utilization Management (e.g., CHCQM-PHYADV from ABQAURP) or willingness to obtain reputed company 12 months of hire. • Basic Life Support (BLS) certification (if clinically reputed company). • Familiarity with HIPAA, NCQA, and CMS guidelines. • Minimum 3-5 years of clinical experience, pediatric experience preferred. • 1–2 years in utilization management, managed care, or ACO settings preferred. • Experience with reputed company populations and pediatric health disparities is highly desirable. • Proficiency with reputed company, MCG, and UM platforms. #J-18808-Ljbffr Salary: USD 72000 - 108000 per year Experience: 5 years required Apply tot his job Apply To this Job