This physician role focuses on reviewing requests for authorization and claims payment to determine medical necessity in a utilization management setting. The work centers on chart-based clinical review, documentation review, and timely case determinations across multiple lines of business. The reviewer also collaborates with utilization management, care management, and other medical departments as needed.
Key Responsibilities
- Review authorization requests and claims payment cases using medical records and internal information.
- Render medical necessity determinations within regulatory and operational timeframes.
- Collaborate with utilization management, care management, and other medical teams on case review and prioritization.
- Maintain productivity standards and manage assigned caseloads across multiple lines of business.
- Adapt to changing case volumes and shifting organizational priorities.
- Complete required compliance training, system training, and annual inter-rater reliability testing.
- Document work hours in Workday each day and follow company policies for time off and coverage.
- Provide weekend and holiday coverage as assigned.
Required
- Licensed M.D. or D.O., or D.M.D. or D.D.S.
- Board certified in a specialty recognized by the American Board of Medical Specialties.
Preferred
- Board certified in Internal Medicine, Family Practice, or Emergency Medicine.
- Previous experience in utilization management and clinical practice.
- Knowledge of Medicare, Medicaid, and MLTC plans.
- Familiarity with UM/QM case philosophies and state and federal reporting requirements.
- Experience with quality improvement methodologies.
Benefits & Perks
- Competitive salary range provided in the posting.
- Medical, dental, and vision coverage.
- Incentive and recognition programs.
- Life insurance and 401(k) contributions.
- Paid time off.
- Holiday pay for required holiday coverage.