Utilization Management Physician Reviewer

The Utilization Management Physician Reviewer will be responsible for providing thorough and accurate reviews of utilization management cases to ensure the appropriate use of medical resources while continuing to hold high standards of patient care. The position will involve collaborating closely with both the Medical Director, other team members, and clients to conduct reviews with a high level of accuracy and efficiency. This collaboration ensures that reviews are thorough, well documented, and align with established medical guidelines and standards.

• Perform utilization management reviews in an efficient and timely manner, ensuring each review is completed with careful attention to detail while maintaining high quality work.
• Review appeals or complaints that relate to medical review decisions by conducting a thorough assessment of all medical records, treatment plans, and other supporting documents from healthcare providers.
• Collaborate with the Medical Director and Senior Management to ensure effective coordination of the delivery of services to clients.

• Communicate with client Medical Directors and other stakeholders regarding the utilization management process; provide detailed explanation of review outcomes, address questions and concerns and ensure all parties are aware of any changes or updates in the process.
• Participate in the quality improvement of all steps in the review process.
• Act as a medical resource and provide guidance to Pharmacists and other team members regarding clinical questions.
• Communicate clearly and professionally with clients at regular meetings regarding quality and production.
• Audit cases and provide quality feedback as needed.
• Perform all other duties as assigned by management.

MD, DO, or DPM degree required. Current, active unrestricted license to practice medicine required. Minimum of five years of experience in medical practice required.

• Must have a Board Certification in an ABMS or AOA-recognized specialty required if an MD or DO. Current active, unrestricted license to practice medicine required.
• Ability to provide clinical guidance regarding the quality and/or clinical aspects of reviews and, when appropriate, directly communicates with reviewers, staff, and/or clients.
• Ability to travel as required.
• Ability to interact with clients as needed, either independently or as a participating member of a group discussion between service and client, regarding the clinical quality aspects of the medical reviews.
• Must be able to review cases and data thoroughly to ensure that all necessary information meets quality standards.
• Must have strong knowledge of medical terminology and procedures, which may include utilization reviews, quality-assurance services compliance, and claims analysis.
• Must have knowledge of federal and/or state legislative mandates (ERISA and/or state law).
• Must be able to work well under pressure and or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Must be able to maintain confidentiality.
• Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.