Top 632 Utilization reviewer Jobs

Medical Peer Reviewer
Healthfirst —Remote
- $122,907 - $188,020 a year
- 8 hour shift
- Medicine
- Mid-level
- Communication skills
- Paid holidays
- Health insurance
Initial Clinical Reviewer
Enlyte —Remote
- $59,000 - $73,000 a year
- Full-time
- Remote
- Clinic experience
- Mid-level
- Analysis skills
- Health savings account
- AD&D insurance
Intake Representative - ALBUQUERQUE, NM
COMAGINE HEALTH —New Mexico
- $20 - $23 an hour
- Remote
- Mid-level
- High school diploma or GED
- Ability to sit for extended periods
- Paid parental leave
- Health insurance
Quick Apply
Appeals Assistant Remote
University Hospitals —Shaker Heights, OH
- $18.12 - $28.35 an hour
- Remote
- Medical office experience
- Research
- Mid-level
14d
Utilization Reviewer (Applied Behavior Analysis)
Hawaii Medical Service Association —Honolulu, HI
- Applied behavior analysis
- Mid-level
Physician Reviewer - Utilization Management (Part Time)
Oscar Health —New York, NY
- $130 - $145 an hour
- Part-time
- Remote
- Medicine
- BC/BE
- Travel
- Paid parental leave
- Paid holidays
Quick Apply
9d
Utilization Review Specialist
We Level Up —Pompano Beach, FL
- $50,000 - $90,000 a year
- Full-time
- Remote
- 18 years or older
- CPR Certification
- HIPAA
Quick Apply
Utilization Review & Quality Assurance Specialist
ExamWorks —Rockford, IL
- $45 - $52 an hour
- Full-time
- Remote
- Anatomy knowledge
- Microsoft Outlook
- RN License
- Health insurance
- Dental insurance
Quick Apply
14d
ECM Enrollment Representative - Remote
Medzed LLC —San Antonio, TX
- $20 an hour
- Full-time
- Remote
- Spanish
- HIPAA
- English
Quick Apply
Coordinator, UM Intake
Evolent Health —Remote
- $18 - $20 an hour
- Full-time
- Background check
- Computer literacy
- Pass drug screening
- Health insurance
RN Reviewer
Cohere Health —Remote
- $33 - $35 an hour
- Full-time
- Remote
- Google Workspace
- Nursing
- RN License
- Paid parental leave
- Health savings account
Quick Apply
Utilization Management Clinical Reviewer
CuraFi —Remote
- $140,000 - $160,000 a year
- Full-time
- RN License
- Senior level
- Communication skills
- Health insurance
- Dental insurance
Quick Apply
14d
Medical Consultant Reviewer - Internist PRN or Part-Time
COMAGINE HEALTH —Washington, DC
- $140 - $148 an hour
- Part-time
- Remote
- Medicine
- Internal Medicine
- Travel
- Paid parental leave
- Health insurance
Quick Apply
UTILIZATION REV SPEC I
Aspire Health Partners —Orlando, FL
- Full-time
- Clean driving record
- High school diploma or GED
- Driver's License
Quick Apply
Referral Management (Non-Nurse) Reviewer
Zimmerman Associates, Inc. —Bethesda, MD
- $24.13 an hour
- Microsoft Excel
- Microsoft Outlook
- Customer service
Geotechnical Department Manager I
Terracon —Tulsa, OK
- Management
- 5 years
- Master's degree
Referral Management (Non-Nurse) Reviewer
Zimmerman Associates, Inc. —Bethesda, MD
- $23.56 an hour
- Microsoft Excel
- Microsoft Outlook
- Mid-level
Behavioral Health Physician Reviewer
Toney HealthCare Consulting, LLC —Remote
- $175 - $200 an hour
- Part-time
- Remote
- Medicine
- Psychiatry
- Senior level
Quick Apply
BCBA Clinical Director
GBE Alliance —Hopkinsville, KY
- Full-time
- Background check
- 3 years
- Master's degree
- Paid holidays
- Dental insurance
Quick Apply
Therapist (AMFT, ASW, APCC) Santa Clarita - Mental Health and Substance Use
Santa Clarita Behavioral Health —Valencia, CA
- $33 - $40 an hour
- Part-time
- Background check
- Computer literacy
- Mid-level
- Health insurance
- Dental insurance
Quick Apply

I want to receive the latest job alert for utilization reviewer

By signing in to your account, you agree to SimplyHired's Terms of Service and consent to our Cookie and Privacy Policy.

Explore jobs in more locations

utilization reviewer jobs near

Medical Peer Reviewer

Healthfirst -
Remote

Apply Now

Job Details

Part-time
$122,907 - $188,020 a year

Benefits

Paid holidays
Health insurance
Dental insurance
401(k)
Paid time off
Vision insurance
Life insurance

Qualifications

Medical License

Full Job Description

Job Profile Summary A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations.

Duties/Responsibilities:

The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies.
The Medical Peer Reviewer will:
Maintain productivity standards.
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software.
Enter each day’s hours worked in Workday, on the same day.
Perform other duties as assigned
Responsibilities may be adjusted based on changing needs of the organization.

Weekday Requirements:

The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage
The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday.
Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked
The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy.

Weekend Requirements:

Each Medical Reviewer is required to be primary coverage one weekend a month
Each Medical Reviewer is required to be available as back up, if needed, one weekend a month
Dental Reviewers have a fixed schedule

Minimum Qualifications:

Licensed M.D. or D.O. or D.M.D. or D.D.S.

Board Certified in a specialty recognized by the American Board of Medical Specialties

Preferred Qualifications:

Board Certified in Internal Medicine , Family Practice, Emergency Medicine
Previous, relevant experience in utilization management and clinical practice
Knowledge of Medicare, Medicaid, and MLTC plans
Time management, critical thinking, communication, and problem-solving skills
Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
Knowledge of member satisfaction/incident management and regulations
Knowledge of quality improvement methodologies

Compliance & Regulatory Responsibilities: Ensures compliance to internal Healthfirst and external regulations.

Licensed M.D. or D.O. or D.M.D. or D.D.S.
Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
Annual Inter-Rater Reliability (IRR) Testing
Complies with the Healthfirst Conflict of Interest Policy for Professionals

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $122,907 - $188,020

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

Apply Now

Refine Your Search

utilization reviewer jobs

Medical Peer Reviewer

Initial Clinical Reviewer

Intake Representative - ALBUQUERQUE, NM

Appeals Assistant Remote

Utilization Reviewer (Applied Behavior Analysis)

Physician Reviewer - Utilization Management (Part Time)

Utilization Review Specialist

Utilization Review & Quality Assurance Specialist

ECM Enrollment Representative - Remote

Coordinator, UM Intake

RN Reviewer

Utilization Management Clinical Reviewer

Medical Consultant Reviewer - Internist PRN or Part-Time

UTILIZATION REV SPEC I

Referral Management (Non-Nurse) Reviewer

Geotechnical Department Manager I

Referral Management (Non-Nurse) Reviewer

Behavioral Health Physician Reviewer

BCBA Clinical Director

Therapist (AMFT, ASW, APCC) Santa Clarita - Mental Health and Substance Use

I want to receive the latest job alert for utilization reviewer

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected