Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. 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.
Directs daily involvement in the following utilization management functions:
Reviews all cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request by phone or fax.
Provides clinical rationale for standard and expedited appeals.
Provides assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
Utilizes medical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as URAC and NCQA guidelines.
Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.
Participates in on-going training per inter-rater reliability process.
Assists the Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
General Job Information
Part Time Physician Reviewer
Clinical Services Group
United States of America
United States of America (Non-Exempt)
Recruiting Start Date
Date Requisition Created
License and Certifications - Required
DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician
License and Certifications - Preferred
Other Job Requirements
Current, unrestricted license to practice medicine in one or more states of the United States. Board Certified by one of the following: the American Board of Physical and Rehabilitation Medicine (ABPRM), American Board of Medical Specialties (ABMS), American Board of Nuclear Medicine (ABNM), American Board of Cardiovascular Medicine (ABCMC), American Board of Anesthesiology (ABA) or American Board of Osteopathic Specialties (ABOS). Graduate degree from an accredited medical school.Familiarity with the principles and procedures of utilization management as practiced in managed care organizations, experience with cost benefit analysis, quality assurance and the continuous quality improvement process is desirable.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled