Conduct remote clinical case reviews for post-acute care requests to support medical-necessity decisions, including physician-to-physician discussions when additional clinical information is needed. The role also supports utilization management workflows, documentation, and consistent application of clinical policies and criteria across review cases. In addition, it may involve peer-to-peer appeal reviews, quality improvement activities, and collaboration with nursing and other clinical teams.
Key Responsibilities
- Conduct timely clinical case reviews for post-acute care requests
- Conduct physician-to-physician calls to gather information needed for determinations
- Apply medical policies, clinical guidelines, and criteria consistently
- Document determinations, outreach attempts, and rationale in company systems
- Collaborate with nursing and utilization management staff to support throughput and decisioning
- Participate in peer-to-peer appeal reviews and appropriateness reviews as assigned
- Assist with quality improvement initiatives, medical technology assessments, and provider credentialing as needed
Required
- MD or DO degree with active, unrestricted licensure
- At least 3 years of clinical experience in inpatient or post-acute care
- At least 1 year of experience conducting medical-necessity clinical case reviews
- Ability to apply clinical criteria and policies and communicate decisions effectively
- Strong documentation skills and ability to meet turnaround-time requirements
Preferred
- Prior experience in utilization management, health plan medical management, or managed care
- Experience with post-acute settings such as SNF, IRF, LTACH, or home health
- Familiarity with clinical criteria tools such as MCG
Benefits & Perks
- Remote work
- Ongoing assignment
- May participate in a physician on-call rotation for a 24x7 unit