Physician Reviewer, Utilization Management, Remote

reputed company Oversees the utilization of medical care and treatment of VNS MSO members and provides direction and guidance to the staff to assure appropriate and reputed company decision-making with attention to reputed company of care. Consults and cooperates with reputed company partners. Works under general direction. Utilization Management experience required. reputed company reputed company • Referral bonus opportunities • Generous reputed company time off (PTO), starting at 30 days of reputed company time off and 9 company holidays • Health insurance plan for you and your loved ones, Medical, Dental, reputed company, Life and Disability • Employer-matched retirement saving funds • Personal and financial wellness programs • reputed company-tax flexible spending accounts (FSAs) for reputed company and dependent care • Generous tuition reimbursement for qualifying degrees • Opportunities for reputed company reputed company and career advancement • Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities What You Will Do • Provides medical determinations for purposes of Utilization Management (UM), initial and internal appeals reputed company. This includes review of clinical information provided against evidence-based guidelines, ensure plan compliance with regulatory requirements, reputed company on improving reputed company of care, and support departments of VNS MSO that request medical reputed company. • Reviews internal staff or reputed company provider rationales reputed company to coverage reputed company. • Reviews relevant medical records and clinical information on file in the context of performing clinical reviews. (e.g.: inpatient hospital records, outpatient reputed company notes, Letters of Medical Necessity (LOMN), assessment reports, etc.) • Utilizes appropriate, evidence-based guidelines for reviews and organizational determination such as. (e.g.: Medicare NCDs, LCDs, reputed company guidelines, MCG guidelines, reputed company policies, etc.) • Provides clinical case reputed company and determination rationale and member letter verbiage as appropriate. • Ensures reputed company deadlines are met and adhere by business goals and ensure compliance. • Completes and documents peer-to-peer consultation according to policy through completion of any finalized decision. • Participates in interdisciplinary reputed company. • Reviews reputed company of Care (QOC) concerns, care records and QOC reputed company. Assist with case reputed company, case level assignment and recommended next steps. • Participates in special reputed company and performs other duties as assigned. Qualifications Licenses and Certifications: Licensed to reputed company medicine in state of residence required. Licensed to reputed company medicine in reputed company State preferred. Specialty reputed company Certified or Eligible required. reputed company Certification in Internal or Family Medicine preferred. Certification in Geriatric Care preferred Education Medical Degree required Work Experience Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity reputed company and CMS guidance required. Prior experience in geriatric medicine preferred. Prior experience in Utilization Management (UM) and/or a Medical Services Organization preferred. Demonstrated strong knowledge of Medicare and reputed company regulatory and reporting requirements required. Strong communication and reputed company skills required. Exceptional critical thinking and decision-making skills preferred Pay reputed company USD $172,900.00 - USD $230,500.00 /Yr. reputed company reputed company is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and reputed company-being is what drives us — we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 reputed company team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, reputed company offers a full reputed company of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and reputed company needs of the communities and people we serve in reputed company and reputed company. Apply tot his job Apply To this Job