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 healthcare professionals to ensure appropriate, timely, and cost-effective care for members.
Key Responsibilities:
- Conduct physician-level reviews of prior authorization, concurrent review, and retrospective review cases across multiple lines of business (e.g., commercial, Medicaid, Medicare).
- Apply nationally recognized clinical criteria (e.g., MCG, InterQual), internal medical policies, and applicable regulations (CMS, NCQA, URAC) to review determinations.
- Render clinical decisions in a timely manner consistent with regulatory timeframes and health plan policies.
- Collaborate with medical directors, case managers, and care teams to support optimal care pathways.
- Participate in audits, appeals, and grievance processes as needed.
- Maintain current knowledge of clinical best practices, industry trends, and regulatory changes.
- Participate in peer-to-peer discussions with attending physicians to communicate UM decisions 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.
- Provide guidance on clinical appropriateness, benefit coverage, and policy interpretation.
- Provide education and clinical support to internal teams and external providers regarding best practices and clinical pathways.
- Ensure compliance with regulatory, accreditation, and legal requirements in all UM activities.
- Ensure adherence to all HIPAA, confidentiality, and privacy standards.
- Participate in quality improvement initiatives and clinical case rounds
Qualifications:
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree required.
- Active and unrestricted medical license.
- Minimum of 5 years of clinical practice experience in the respective specialty.
- At least 3 years of experience in utilization management within 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/Medicaid and commercial insurance regulations is preferred.
- Preferred Skills:Experience with Medicare and/or Medicaid 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, collaborative environment.
This is remote, contract work.
