Job DescriptionKey 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.
We are currently recruiting board certified physicians in these specialties: gastroenterology, neurology, anesthesiology, oncology and internal medicine.
- Directs daily involvement in the 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 time frame 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 VP, Medical Affairs 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 Affairs.
General Job Information
TitlePhysician Clinical Reviewer, MRx - REMOTE
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date11/21/2019
Date Requisition Created11/21/2019
EducationDO (Required), MD (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) - Physician
License and Certifications - Preferred
Other Job Requirements
- Current, unrestricted license to practice medicine or chiropractic 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).
A licensed Physician with one of the following specialties: Endocrinologist, Neurologist, Oncologist, or Rheumatologist, Internal Medicine, Infectious Disease
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.
Medicare Part D experience preferred.
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 position.
Top 5 reasons to work at Magellan
Meaningful Work With People Who Care
At Magellan Health you can do meaningful work and feel confident that you matter in an organization that makes a real difference in the world - one that cares deeply and uses its employees’ collective insight as a competitive advantage.Read More
We are Compassionately Curious
Magellan Health is a place where we listen with real empathy. It’s one of our biggest strengths. It helps us to support each other and develop innovative solutions for the fastest growing, most complex areas of healthcare.Read More
We are Better Together
We rely on our innate ability to work as a high-functioning collaborative team to facilitate compassionate care to all of our members. With such interdependency comes trust, challenge and innovation.Read More
We believe work and life should flow together in unison. We offer resources that match your professional development, a culture that welcomes your ideas, and unparalleled flexibility to fit work around your life.Read More
Be your best at Magellan Health. We’re a collective of remarkably motivated and driven professionals. As a team, we’re proud of the high standards we set for each other and we’re continually inspired to do our best work.Read More
When you sayLife @ Magellan
To be the best you have to work with the bestWe hear you