Physician Clinical Reviewer

Magellan Health
Published
September 1, 2022
Location
United States
Category
Other  
Job Type
Work Setting
In-office

Description

Must be Board Certified in Internal Medicine

Must have knowledge and experience in the Cardiology area

A key member of the utilization management team, and provides a timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required.

Directs daily involvement in the following utilization management functions:

  • Reviews all 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 timeframe 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 MD review process so as to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as URAC and NCQA guidelines.
  • Ensures documentation of all communications with medical office staff and/or MD providers is recorded in a timely and accurate manner.
  • Participates in ongoing training per inter-rater reliability process.
  • Assists the Senior 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 Senior Medical Director.

Other Job Requirements

Responsibilities

Doctor of Medicine (MD) degree OR Doctor of Osteopathic Medicine (DO) degree OR Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of United States based internship and residency (and successful completion of United States based fellowship for subspecialists) required.
Current, unrestricted license to practice medicine in one or more states of the United States.
Board Certified by one of the following: the American Board of Physical and Rehabilitation Medicine (ABPRM), American Board of Medical Specialties (ABMS), American Board of Nuclear Medicine (ABNM), American Board of Anesthesiology (ABA), American Board of Osteopathic Specialties (ABOS), American Board of Internal Medicine or American Board of Osteopathic Internal Medicine (ABIM/ABOIM).
A licensed Physician practicing in a specialty such as an Anesthesiologist, Emergency Medicine, Family Medicine, Gastroenterologist, Neurologist, Oncologist, Otolaryngologist, Pain Management, Physical Medicine, Radiologist, or Urologist.
Familiarity with the principles and procedures of utilization management as practiced in managed care organizations, experience with cost-benefit analysis, quality assurance, and the continuous quality improvement process are desirable.

Work Experience - Required

Medical

Work Experience - Preferred

Education - Required

DO, MBBS, MD

Education - Preferred

License and Certifications - Required

DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MBBS - Bachelor of Medicine, Bachelor of Surgery - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician

License and Certifications - Preferred

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