Reviews pre- and post-service clinical requests from members and providers, applying clinical judgment and utilization management criteria to determine medical necessity and coverage. Works across a broad range of specialty requests and may conduct peer-to-peer discussions with treating providers when needed. Also provides clinical leadership and support to other areas of the organization and participates in unit quality improvement efforts.
Key Responsibilities
- Analyze clinical documentation and apply coverage criteria and guidelines to determine medical necessity for requested services.
- Conduct peer-to-peer outreach with treating providers when appropriate to support coverage determinations.
- Document utilization management decisions in the review system to support provider and member letters.
- Complete determinations in a timely manner while meeting productivity, NCQA, MCRA, FEP, Medicare, and other applicable standards.
- Collaborate with a team of board-certified physicians across specialties and share best practices to improve unit effectiveness.
- Participate in quality improvement activities and contribute to a positive team environment.
- Provide clinical leadership to other areas of the organization when requested by medical leadership.
Required
- MD or DO degree.
- Active specialty board certification.
- Current, valid, unrestricted Massachusetts medical license.
- Active clinical practice.
- Experience in utilization management in a managed-care or risk-contract environment.
Preferred
- Leadership experience with the ability to motivate and develop staff.
- Experience with committee work, large group practice, or peer review.
- Strong collaboration, negotiation, written, and oral communication skills.
- Ability to manage conflict effectively over the phone.
Benefits & Perks
- Full-time role.
- Variable pay eligibility.
- Comprehensive benefits package including medical, dental, and vision insurance.
- Paid time off.
- 401(k) plan.
- Well-being benefits.