Physician Clinical Reviewer - Rheumatology- REMOTE

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting Title Physician Clinical Reviewer - Rheumatology- REMOTE

Job Description

The Physician Clinical Reviewer is a 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. This role 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. Responsibilities Physician Clinical Reviewer –

Job Description

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.

Minimum Qualifications

Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO) 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: 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) 1 year of work experience in clinical review Must be eligible to work in the United States without the need for work visa or residency sponsorship. Additional Qualifications Familiarity with the principles and procedures of utilization management as practiced in managed care organizations