In this non-clinical utilization management role, the clinician reviews vascular surgery cases that do not initially meet medical necessity guidelines and provides specialty-level determinations for imaging and other requests. The work includes peer-to-peer discussions with ordering providers, appeal review, and support for consistent medical policy application. The role collaborates closely with physicians, leadership, and review staff and may also serve as a medical director for select plans or regions.
Key Responsibilities
- Review vascular surgery cases that do not initially meet medical necessity guidelines.
- Conduct specialty reviews for imaging and other requests when required by providers, clients, or state laws.
- Discuss determinations with requesting physicians or ordering providers within required timeframes.
- Provide clinical rationale for standard and expedited appeals.
- Use medical review guidelines and parameters to support consistent utilization review decisions.
- Support initial clinical reviewers with specialty input and clinical guidance.
- Document all communications with medical office staff and physicians accurately and promptly.
- Participate in ongoing training and inter-rater reliability processes.
Required
- MD, DO, or MBBS degree.
- Current, unrestricted clinical license in medicine or the required specialty.
- Active board certification in Vascular Surgery, or active board certification in General Surgery with extensive vascular surgery experience.
- Ability to obtain and maintain medical licenses in the state of residence.
- Strong clinical, management, communication, organizational, and computer skills.
Preferred
- At least 5 years of experience practicing vascular surgery.
Benefits & Perks
- Work-from-home technical setup with high-speed internet required.
- Comprehensive benefits, including health insurance benefits, for qualifying employees.
- Expected base salary of $130-$140/hr.
- Work/life balance and scheduling flexibility.
- Autonomy in a non-clinical environment.
- Opportunities for collaboration and continuous learning.