Physician Clinical Reviewer- Remote Opportunity
Company: Magellan Health
Location: Las Vegas
Posted on: July 1, 2020
Currently seeking hours of coverage 12pm-6pm Central Time
Mondays, Wednesdays, Fridays
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
- 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
- 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
- Participates in on-going training per inter-rater reliability
- 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
General Job Information
TitlePhysician Clinical Reviewer- Remote OpportunityGrade33Job
FamilyClinical Services GroupCountryUnited States of AmericaFLSA
StatusUnited States of America (Non-Exempt)Recruiting Start
Date12/13/2019Date Requisition Created12/13/2019Work
ExperienceClinicalEducationMD (Required)License and Certifications
- RequiredDO - Physician, State Licensure and Board Certified (ABMS
or Specialty Board) - Physician, MD - Physician, State Licensure
and Board Certified (ABMS or Specialty Board) - PhysicianLicense
and Certifications - Preferred
Other Job Requirements
- 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.
- Current and active license in good standing in the state in
which Physician works required, Interstate Medical Licensure
Compact strongly preferred.
- Current 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 Cardiovascular Medicine (ABCMC),
American Board of Anesthesiology (ABA), American Board of
Osteopathic Specialties (ABOS), American Board of Internal Medicine
or American Board of Osteopathic Internal Medicine
- A licensed Physician practicing as one of the following: Family
Practice, Internal Medicine, Emergency Medicine, Neurologist,
Oncologist, Radiologist or Urologist.
Magellan Health Services is proud to be an Equal Opportunity
Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every
employee must understand, comply and attest to the security
responsibilities and security controls unique to their
Keywords: Magellan Health, Las Vegas , Physician Clinical Reviewer- Remote Opportunity, Healthcare , Las Vegas, Nevada
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