Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
Discuss cases with physician providers (Peer to Peer)
Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
Participate in the development and review of Medical and Pharmacy policies as assigned
Support the organization as a subject matter expert
Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
Perform other duties as assigned and needed by the organization
Job Requirements
Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
5+ years of clinical experience
Experience working in a dynamic, fast-paced environment
Experience working both independently and in a team environment
Exceptional verbal and written communication
Preferred
Physician reviewer or utilization management experience
Primary Care Specialty physician experience
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
What We Offer
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
Medical, dental, vision, life and global travel health insurance;
Income protection benefits: life insurance, Short- and long-term disability programs;
Leave programs to support personal circumstances;
Retirement Savings Plan includes employer contribution and employer match;
Paid time off, volunteer time off, and 11 holidays
Additional voluntary benefits available; and
A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.
About Us
At GuideWell, we are committed to making diversity, equity and inclusion part of everything we do. We believe in hiring people who represent the communities we serve while creating a workplace that encourages a sense of belonging for everyone, no matter who you are or where you come from.
From students to former military to seasoned professionals, our family of mission-based companies are stronger because of the unique talents and skills of our employees. We believe everyone’s contribution has the power to help people and communities achieve better health. Find your new team today.
About The Team
Florida Blue, A GuideWell Company, has been providing health insurance to residents of Florida for 75 years. Driven by its mission of helping people and communicating to achieve better health, the company serves more than five million health care members across the state. We are looking for exceptional people who will bring our mission to life and succeed by putting the members first.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Government Administration
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