Physician Clinical Reviewer - Rheumatology- REMOTE

Prime Therapeutics•Home, WV

8d•Remote

About The Position

Prime Therapeutics (Prime) is a different kind of PBM with a purpose beyond profits and a unique ability to connect care for those they serve. This role is a key member of the utilization management team, providing timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. The Physician Clinical Reviewer 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.

Requirements

Must be eligible to work in the United States without the need for work visa or residency sponsorship.
DO
MBBS
MD
5+ years of clinical experience

Nice To Haves

Physician Clinical Reviewer - Rheumatology

Responsibilities

Reviews 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 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 physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines.
Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
Participates in on-going inter-rater reliability training and testing.
Assists the Medical Director and/or VP, 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 VP, Medical Director.
Other duties as assigned.