UM Physician Reviewer

· Review clinical documentation, including patient charts, treatment plans, and diagnostic reports, to assess the medical necessity of requested services.

· Utilize evidence-based clinical guidelines (e.g., InterQual, Milliman) to determine if the requested treatment, service, or procedure is appropriate and necessary based on the patient's clinical condition.

· Provide timely and accurate clinical decisions regarding the approval, modification, or denial of healthcare services.

· Collaborate with healthcare providers, utilization management teams, and insurance companies to ensure accurate and efficient review processes.

· Serve as a clinical resource for the utilization management department by providing expert guidance on complex cases and reviewing difficult decisions.

· Communicate clinical decisions clearly and effectively to providers, explaining the rationale behind approvals, denials, or modifications of services.

· Review and process appeal requests, including medical necessity disputes, providing clinical expertise to reassess initial decisions when required.

· Work with insurance companies, providers, and patients to resolve any issues related to denials of services, ensuring clear communication and timely resolutions.

· Ensure all utilization management practices comply with regulatory requirements, industry standards, and company policies.

· Participate in audits and quality improvement initiatives to ensure the integrity and accuracy of the utilization management process.

· Monitor trends in care patterns and identify areas where process improvements may be needed.

· Maintain thorough and accurate documentation of all reviews and decisions made regarding medical necessity and appropriateness of services.

· Document rationale for decision-making, including reference to specific clinical guidelines and criteria.

· Provide reports and data on utilization management activities to department leaders and stakeholders as needed.

· Unrestricted, Active Licensed Medical Doctor (MD) or Doctor of Osteopathy (DO)

· Unrestricted license to practice in the state where services are being performed

· Stay current with clinical developments, medical technologies, treatment protocols, and insurance policies related to utilization management.

· Provide education and support to clinical staff and healthcare providers regarding medical necessity, authorization processes, and utilization management guidelines.

• Unrestricted, Active Licensed Medical Doctor (MD) or Doctor of Osteopathy (DO)
• Unrestricted license to practice in the state where services are being performed

Pay Rate:  350- $500 per review.