Physician reviews behavioral health service appeals by assessing records, applying medical necessity criteria, and determining whether managed care decisions align with evidence-based standards and guidelines. The role also includes preparing written reviews, editing other reviewers’ determinations, and providing expert testimony in appeal hearings as needed. Work is primarily remote, with onsite availability required when the client contract calls for it.
Key Responsibilities
- Conduct independent medical service appeal reviews for behavioral health cases.
- Review clinical records and prepare timely written medical necessity determinations.
- Evaluate managed care, dental benefits manager, and pharmacy benefits manager decisions against applicable guidelines and protocols.
- Apply standards of care, rules of medical necessity, and evidence-based medicine in appeal analysis.
- Edit medical necessity reviews completed by other physicians.
- Provide expert medical witness testimony in appeals hearings and consult with legal counsel as needed.
- Participate in quality assurance activities related to review outcomes and hearing decisions.
- Collaborate with medical, nursing, and administrative staff on shared case issues.
Required
- MD or DO degree.
- Current non-restricted medical license in the State of Maine.
- Utilization review experience in behavioral health services.
- Working knowledge of quality assurance and utilization review.
- At least 3 years of clinical practice experience.
- Experience with Medicaid.
Preferred
- Ability to work effectively with diverse personalities.
- Approachable, respectful, and consensus-oriented communication style.
- Strong collaborative and adaptable management style.
- Excellent writing skills.
- Proficiency with MS Office Suite.
Benefits & Perks
- Primarily remote work with onsite work only as contractually required.
- Retirement savings support.
- Corporate wellness resources.
- Educational assistance.
- Corporate discounts.
- Pay range of USD $88.70 to USD $140.00 per hour.