This physician role focuses on utilization review for prior authorizations and appeals, using medical records to determine medical necessity against evidence-based guidelines, state rules, and client policies. The work is largely administrative and may include mandated phone calls, written determinations, and quality review of reports before submission. It also involves responding to quality, regulatory, audit, and legal inquiries as needed.
Key Responsibilities
- Review prior authorization and appeal requests, including medical records, to determine medical necessity.
- Provide clear, concise, and well-supported rationales for review determinations.
- Make mandated phone calls and communicate findings in member-friendly language using templates.
- Return cases by the required due date and time.
- Assist with quality assurance review of reports before client submission.
- Use current national, state, and professional association guidelines, along with peer-reviewed literature, to support decisions.
- Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.
- Maintain proper credentialing, state licenses, and special certifications.
Required
- Board-certified M.D. or D.O. with a current, unrestricted clinical license in any U.S. state.
- At least 5 years of postgraduate experience.
- Experience in utilization management and criteria review using standard practice guidelines.
- Working knowledge of URAC and relevant state and federal compliance guidelines.
- Computer literacy and typing skills.
Preferred
- Medicaid and/or Medicare experience.
Benefits & Perks
- Generous paid time off.
- Excellent benefits package.
- Competitive salary.
- Opportunity to work in a fast-paced environment.