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Physician Clinical Reviewer - Physical Medicine and Rehab - R00000051745

at Magellan Health Services, Inc. in Scottsdale, Arizona, United States

Job Description

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.
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 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 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: 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 is desirable.

General Job Information

Title
Physician Clinical Reviewer - Physical Medicine and Rehab

Grade
33

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,...

Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity

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Job Posting: 5185267

Posted On: Jun 08, 2022

Updated On: Jul 08, 2022