Physician Clinical Reviewer- GI - REMOTE

About the position As a key member of the utilization management team, the Physician Clinical Reviewer for Gastroenterology (GI) plays a crucial role in ensuring that patients receive the necessary medical services in a timely manner. This position involves conducting thorough medical reviews of service requests that do not initially meet the applicable medical necessity guidelines. The reviewer will routinely interact with physicians, leadership, management staff, and other Physician Clinical Reviewers (PCR), as well as health plan members and staff, to gather input and provide necessary clinical insights. The role is primarily remote, allowing for flexibility while maintaining a focus on patient care and compliance with established guidelines. The Physician Clinical Reviewer will direct daily involvement in various utilization management functions. This includes reviewing all cases where clinical determinations cannot be made by the Initial Clinical Reviewer. The reviewer will discuss determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request, utilizing phone or fax communication. It is essential to provide clinical rationale for both standard and expedited appeals, ensuring that all communications with medical office staff and/or MD providers are documented accurately and in a timely manner. Additionally, the reviewer will assist Initial Clinical Reviewers by acting as a resource for discussing cases and resolving problems. Utilizing established medical and clinical review guidelines, the reviewer will ensure consistency in the MD review process, reflecting appropriate utilization and compliance with the organization’s policies and procedures, as well as URAC and NCQA guidelines. Participation in ongoing training related to inter-rater reliability processes is also a key component of this role. On an as-needed basis, the Physician Clinical Reviewer may review appeal cases and attend hearings to discuss utilization management decisions. There may also be opportunities to function as a Medical Director for select health plans or regions, assuming overall accountability for utilization management while collaborating with the VP of Medical Affairs. Other duties may be assigned as necessary, contributing to the overall mission of providing high-quality care and service to members. Responsibilities • Review all cases in which clinical determinations cannot be made by the Initial Clinical Reviewer. , • Discuss determinations with requesting physicians or ordering providers within the regulatory time frame of the request. , • Provide clinical rationale for standard and expedited appeals. , • Assist and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems. , • Utilize medical/clinical review guidelines to ensure consistency in the MD review process. , • Ensure documentation of all communications with medical office staff and/or MD providers is recorded accurately and timely. , • Participate in ongoing training per inter-rater reliability process. , • Assist the VP, Medical Affairs in research activities related to the Utilization Management process. , • Review appeal cases and/or attend hearings for discussion of utilization management decisions on a requested basis. , • Function as Medical Director for select health plans or regions on a requested basis. Requirements • Doctor of Medicine (MD) degree OR Doctor of Osteopathic Medicine (DO) degree OR Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of United States based internship and residency. , • Current, unrestricted license to practice medicine or chiropractic in one or more states of the United States. , • Board Certified by one of the following: American Board of Medical Specialties (ABMS), American Board of Osteopathic Specialties (ABOS), American Board of Internal Medicine or American Board of Osteopathic Internal Medicine (ABIM/ABOIM). , • Familiarity with the principles and procedures of utilization management as practiced in managed care organizations. Nice-to-haves • Medicare Part D experience preferred. , • Experience with cost benefit analysis, quality assurance, and the continuous quality improvement process is desirable. Benefits • Health insurance , • Dental insurance , • Vision insurance , • 401k , • 401k matching , • Paid holidays , • Flexible scheduling , • Professional development , • Tuition reimbursement , • Life insurance , • Disability insurance , • Employee discount programs , • Wellness programs Apply Job!