Utilization Management Review Physician-Florida- remote position

Utilization Management Position for Primary Care

Central FL client, a large multi-specialty staff model HMO, is seeking a Utilization Management Physician (UMP).

This full-time, remote position requires critical thinking skills, effective communication, and decisive judgement. The ideal candidate will have a working knowledge of the responsibilities listed.

• Review pre-authorization requests, initial clinical review, and concurrent clinical review cases. Review post-service clinical decisions, including claims and appeals.

• Render determinations based on relevant clinical information, medical necessity determined by using evidence-based medicine, nationally recognized criteria (i.e. MCG (formally Milliman), InterQual, Centers for Medicare and Medicaid), client Protocols, and the Member’s client Coverage Documents.

• Review clinical criteria and scripts at least annually and update if necessary.

• Assist the CMO in Provider education regarding treatment protocols, treatment options, etc., as appropriate.

• Be available to client UM staff to answer questions regarding cases under review.

• Be available for peer-to-peer discussions of cases under initial or concurrent review either in person, by telephone, or electronically.

• Meet current regulatory standards regarding pre-authorization determinations.

• Be available to discuss urgent cases directly with attending provider.

• For non-certification decisions, specifies the principal reason for the determination not to certify and the clinical rationale for the non-certification.

• Consult with other physicians in medical specialty areas as needed.

• Participate in client committees at the request of the CMO.

Practitioner Requirements Practitioner must meet the following minimum requirements to serve as a Utilization Management Practitioner(“UMP) for client:

• MD, DO, or PhD degree from an accredited medical school.

• Licensed to practice medicine in the state of Florida without restriction.

• Board certified in primary specialty preferred.

• Have three (3) to five (5) years of clinical experience.

• Knowledge and experience with managed care health plan and benefits

• Ability to provide medical knowledge to facilitate resolution of complex issues and required decisions.

• Working knowledge of medical policy and application of criteria

• Agree to participate in the Interrater Reliability Tool or such other audit process employed by client to ensure consistent application of medical policy and coverage criteria.

Compensation Details

• Competitive salary

• Bonus opportunity

• 401(K) Tax Deferred Plan

• HMO Health Benefits for provider & eligible dependents

• Group Term Life

• Group Disability

• Malpractice Insurance

• Paid Leave Time

• CME Stipend

• Licenses, Fees & Dues reimbursed.

• Travel Reimbursement

• Relocation Assistance