Utilization Management Physician Reviewer
Utilization Management Physician Reviewer
Dane Street
United States
See who Dane Street has hired for this role
Dane Street, a certified "Great Place to Work" company is seeking a Physician to provide utilization review services for the Group Health Department.
This role requires utilizing clinical expertise to review medical records and provide an interpretation of the medical appropriateness of services in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
Dane Street's success relies on individual and team contributions every day. We care for our customers, each other, and Dane Street
Major Duties & Responsibilities
We offer generous Paid Time Off, an excellent benefits package, and a competitive salary. If you want to work in an exciting, fast-paced environment where you can provide meaningful contributions, then we encourage you to apply.
This role requires utilizing clinical expertise to review medical records and provide an interpretation of the medical appropriateness of services in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
Dane Street's success relies on individual and team contributions every day. We care for our customers, each other, and Dane Street
Major Duties & Responsibilities
- Review requests for Prior Authorizations and Appeals including medical records and make a medical necessity determination in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
- Ensure clear, concise, and well-supported rationales for determinations
- Make mandated phone calls
- Provide responses in member friendly language using provided templates
- Return cases on or before the due date and time
- Assist with quality assurance of reports prior to submission to clients
- Maintain proper credentialing, state licenses, and any special certifications
- Utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature for decision-making
- Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits
- Provide copies of any criteria utilized in a review with the report
- Other duties & special projects, as assigned and based on business needs
- Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US
- Minimum five years of postgraduate experience
- Extensive clinical business background required
- Experience in Utilization Management with criteria review utilizing standard practice guidelines
- Medicaid/Medicare experience preferred
- Working knowledge of URAC and relevant State and Federal compliance guidelines
- Excellent communication skills
- High-level understanding of medical insurance and utilization management
- Critical thinking
- Ability to manage time efficiently and meet specific deadlines
- Computer literacy and typing skills required
We offer generous Paid Time Off, an excellent benefits package, and a competitive salary. If you want to work in an exciting, fast-paced environment where you can provide meaningful contributions, then we encourage you to apply.
-
Seniority level
Mid-Senior level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Primary and Secondary Education and Non-profit Organizations
Referrals increase your chances of interviewing at Dane Street by 2x
See who you knowGet notified about new Medical Doctor jobs in United States.
Sign in to create job alertSimilar jobs
People also viewed
-
VA/Federal Physician Reviewer, Optometrist
VA/Federal Physician Reviewer, Optometrist
-
VA/Federal Physician Reviewer, Optometrist
VA/Federal Physician Reviewer, Optometrist
-
Wellness Medical Director (Physician) - Remote | WFH
Wellness Medical Director (Physician) - Remote | WFH
-
Veterans Affairs Physician Reviewer
Veterans Affairs Physician Reviewer
-
VA/Federal Physician Reviewer, Optometrist
VA/Federal Physician Reviewer, Optometrist
-
Tele-Medical Review Orthopedic Opportunity - Physician
Tele-Medical Review Orthopedic Opportunity - Physician
-
Director, Medical Affairs
Director, Medical Affairs
-
Physician / Radiology / New York / Permanent / Teleradiology- Work from Home! - Full time and Part time schedules Job
Physician / Radiology / New York / Permanent / Teleradiology- Work from Home! - Full time and Part time schedules Job
-
Urgent Care On-Call Telemedicine Physician (Remote)
Urgent Care On-Call Telemedicine Physician (Remote)
-
Telehealth Physician - Remote | WFH
Telehealth Physician - Remote | WFH
Looking for a job?
Visit the Career Advice Hub to see tips on interviewing and resume writing.
View Career Advice Hub