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Utilization Management Physician Reviewer
Location
United States
Posted
136 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Utilization Management Physician Reviewer
Dignity Health Management Services
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description As the Utilization Management (UM) Physician Reviewer, you will report to the Medical Director of UM and provide clinical expertise to ensure high-quality, medically necessary, and efficient patient care aligned with regulatory requirements. This role involves making direct decisions in prior authorization, concurrent review of hospitalized patients, and discharge planning. - Clinical review of prior authorization, concurrent review, and retrospective review requests using critical thinking and established guidelines. - Interpreting benefit language and ensuring accurate documentation. - Engaging in peer-to-peer discussions with providers and collaborating with other healthcare professionals. - Handling appeals and grievances while ensuring compliance with federal, state, and accreditation standards. - Acting as a clinical liaison and participating in case reviews and fair hearing processes. - Identifying utilization trends and contributing to policy development and quality improvement. - Guiding UM nurses and clinical staff while staying current with evidence-based medical literature and healthcare trends. This position is remote, but will be expected to work PST business hours. This position is part-time, working approximately 20 hours/week, with flexible days/hours. The schedule includes weekend and holiday rotations ensuring coverage for urgent reviews. Qualifications - Clear and current California MD or DO license. - Proficiency in using electronic health records and UM software platforms (after training). Requirements - 2+ years of experience in a direct patient care setting, Primary care specialty preferred. - Experience in utilization management, medical review, or managed care setting preferred. - Strong knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid / Medicare programs and dual eligible populations, and benefit systems preferred. Benefits - Competitive pay with a flexible Health & Welfare benefits package. - Cafeteria-style benefit program allowing employees to choose benefits from various options, including medical, dental, and vision plans for employees and their dependents. - Health Spending Account (HSA), Life Insurance, and Long Term Disability. - 401k retirement plan with a generous employer-match. - Paid Time Off and Sick Leave.
Job Requirements
- Clear and current California MD or DO license.
- Proficiency in using electronic health records and UM software platforms (after training).
- 2+ years of experience in a direct patient care setting, Primary care specialty preferred.
- Experience in utilization management, medical review, or managed care setting preferred.
- Strong knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid / Medicare programs and dual eligible populations, and benefit systems preferred.
Benefits
- Competitive pay with a flexible Health & Welfare benefits package.
- Cafeteria-style benefit program allowing employees to choose benefits from various options, including medical, dental, and vision plans for employees and their dependents.
- Health Spending Account (HSA), Life Insurance, and Long Term Disability.
- 401k retirement plan with a generous employer-match.
- Paid Time Off and Sick Leave.
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