Physician Clinical Reviewer - Urology- REMOTE

Physician Clinical Reviewer - Urology- REMOTE: A key member of the utilization management team reviews cases and interacts with physicians and health plan members.

Requirements

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
• Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax.
• Provides clinical rationale for standard and expedited appeals.
• Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
• Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines.
• Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
• 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, interpretation, guidelines, and/or system support.
• On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
• On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the VP, Medical Director
• Other duties as assigned.

Benefits

• Generous Paid Time Off
• 401k Matching
• Retirement Plan
• Four Day Work Week