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Job Posting Title

Physician Clinical Reviewer- GI- REMOTE

Job Description Summary

Key member of the utilization management team, and provides 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.

Job Description

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 time frame of the request by phone or fax.Provides clinical rationale for standard and expedited appeals.Provides assistance and act 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 provider is recorded in a timely and accurate manner.Participates in on-going training per inter-rater reliability process.Assists the VP, Medical Affairs 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 VP, Medical Affairs.Other duties as assigned.

Responsibilities

Medicare Part D experience preferred.

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 or chiropractic in one or more states of the United States.

Board Certified by one of the following: American Board of Medical Specialties (ABMS), American Board of Osteopathic Specialties (ABOS), American Board of Internal Medicine

or American Board of Osteopathic Internal Medicine (ABIM/ABOIM).

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 is desirable.

Work Experience

Work Experience - Required:

Clinical

Work Experience - Preferred:

Education

Education - Required:

DO, MBBS, MD

Education - Preferred:

Certifications

Certifications - Required:

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

Certifications - Preferred:

Potential pay for this position ranges from $71.31 - $128.34 based on experience and skills. Pay range may vary by 8% depending on applicant location.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.

Prime Therapeutics LLC is an Equal Opportunity Employer and a Tobacco-free workplace. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, genetic information, marital status, family status, national origin, age, disability, veteran status, or any other legally protected class under federal, state, or local law. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Positions will be posted for a minimum of five consecutive workdays.