In this utilization management role, the clinician reviews imaging cases that do not initially meet medical necessity guidelines and provides physician-to-physician determinations for standard and expedited appeals. The work is primarily non-clinical and focused on radiology review, medical necessity, and compliance, with occasional support for other imaging requests when specialty review is needed. The position involves collaboration with physicians, leadership, and clinical staff in a tech-enabled, quality-focused review environment.
Key Responsibilities
- Review imaging cases that do not initially meet applicable medical necessity guidelines.
- Discuss determinations with requesting physicians or ordering providers through peer-to-peer calls.
- Provide clinical rationale for standard and expedited appeals within required timeframes.
- Use medical review guidelines and parameters to support consistent utilization review decisions.
- Ensure compliance with organizational policies and URAC/NCQA guidelines.
- Support initial clinical reviewers as a physician resource.
- Document all communications with medical office staff and providers accurately and promptly.
- Assist with utilization management research, guideline interpretation, and system support as needed.
Required
- MD, DO, or MBBS degree.
- Active board certification by an accredited organization.
- Current unrestricted clinical license in the home state or required specialty.
- At least 5 years of post-residency clinical practice experience.
- Active clinical practice within the last 2 years is preferred by the employer.
- Must not be excluded or sanctioned by federal or state health care programs.
Preferred
- Recent active clinical practice.
- Strong clinical, communication, management, and organizational skills.
- Computer proficiency.
- Experience with quality, value-based, or utilization review work.
Benefits & Perks
- Part-time schedule.
- Work/life balance and flexibility.
- Autonomy in a non-clinical work environment.
- Collaborative team setting with ongoing training.
- Home internet technical support requirements for remote work.
- Comprehensive benefits for qualifying employees.
- Expected base salary range of $95-$100.