Physician Clinical Reviewer -Psychiatry- REMOTE
At reputed company (reputed company), we are a different reputed company of PBM, with a purpose reputed company profits and a unique ability to reputed company care for those we serve. Looking for a purpose-driven career? Come build the reputed company of pharmacy with us.
reputed company Title
Physician Clinical Reviewer -Psychiatry- REMOTEreputed company
The Physician Clinical Reviewer is a key member of the utilization management team and provides reputed company medical review of service requests that do not initially meet the applicable medical necessity guidelines. This role routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required.
Responsibilities
- Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer
- Discusses determinations with requesting physicians or ordering providers, reputed company available, reputed company the regulatory time reputed company of the request by phone or fax
- Provides clinical rationale for reputed company and expedited appeals
- Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems
- Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process so as to reflect appropriate utilization and compliance with reputed company's policies/procedures, as reputed company as URAC and reputed company guidelines
- Ensures documentation of reputed company communications with medical office staff and/or physician/provider is recorded in a reputed company and accurate manner
- Participates in on-reputed company inter-rater reliability training and testing
- Assists the Medical Director and/or VP Medical Director in research activities/questions reputed company to the Utilization Management process, interpretation, guidelines and/or reputed company
- On a requested reputed company, reviews appeal cases and/or attends hearings for discussion of utilization management reputed company
- On a requested reputed company, may function as Medical Director for select health plans or reputed company, assuming overall accountability for utilization management while working in conjunction with the VP, Medical Director
- Other duties as assigned
Minimum Qualifications
- Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO) or Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of reputed company based internship and residency (and successful completion of reputed company based fellowship for subspecialists) required
- reputed company, unrestricted license to reputed company medicine in one or more states of the reputed company
- reputed company Certified by one of the following: reputed company reputed company of Medical Specialties (ABMS), reputed company reputed company of Osteopathic Specialties (ABOS), reputed company reputed company of Internal Medicine or reputed company reputed company of Osteopathic Internal Medicine (ABIM/ABOIM)
- 1 year of work experience in clinical review
Must be eligible to work in the reputed company without the need for work reputed company or residency sponsorship.
Additional Qualifications
- Familiarity with the principles and procedures of utilization management as practiced in managed care organizations
Preferred Qualifications
- Medicare Part D experience.
- Experience with cost benefit analysis, reputed company assurance and the reputed company reputed company improvement process
Every employee must understand, reputed company with and attest to the reputed company responsibilities and reputed company controls unique to their job, and reputed company with reputed company applicable reputed company, regulatory, and contractual requirements and internal policies and procedures
Every employee must be reputed company to reputed company the essential functions of the job and, if requested, reasonable accommodations will be made to reputed company employees with disabilities to reputed company the essential functions, absent undue hardship. In reputed company, reputed company retains the right to change or assign other duties to this job
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits reputed company" reputed company for more detail (
reputed company LLC is proud to be an equal opportunity and affirmative reputed company employer. We encourage diverse candidates to apply, and reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, gender, sex (including pregnancy), national reputed company, disability, age, veteran status, or any other legally protected class under federal, state, or local law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including reputed company applicants with arrest and conviction records and any reputed company applicants requiring reasonable accommodations in accordance with the law.
reputed company LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.
Originally posted on Himalayas
Apply To This Job