Physician Clinical Reviewer -Family Practice- REMOTE

Prime Therapeutics is seeking a Physician Clinical Reviewer to provide timely medical review of service requests and interact with physicians, leadership, and management staff.

Requirements

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer
• Discusses determinations with requesting physicians or ordering providers
• Provides clinical rationale for standard and expedited appeals
• Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process
• Ensures documentation of all communications with medical office staff and/or physician/provider
• Participates in on-going inter-rater reliability training and testing
• Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process
• Reviews appeal cases and/or attends hearings for discussion of utilization management decisions
• May function as Medical Director for select health plans or regions

Benefits

• Generous Paid Time Off
• 401k Matching
• Retirement Plan
• Tuition Reimbursement