Utilization Management Physician Reviewer

United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must be Board Certified M.D. or D.O. with a current, unrestricted clinical license in any state in the United States. They should possess a minimum of five years of postgraduate experience and extensive clinical business background, with preferred experience in Utilization Management utilizing standard practice guidelines. Familiarity with Medicaid/Medicare is also desired.

Responsibilities

The Utilization Management Physician Reviewer will review requests for Prior Authorizations and Appeals, including medical records, and determine the medical necessity of services in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies. This role involves providing clear rationales for determinations, making mandated phone calls, responding to members in a friendly manner using provided templates, returning cases on time, assisting with quality assurance, maintaining credentialing, and utilizing relevant criteria and resources for decision-making. They will also identify and respond to quality assurance issues, regulatory issues, and other related matters, as well as providing copies of utilized criteria with the report, and performing other duties and special projects as assigned.

Skills

Utilization Review

Medical Necessity Determination

Prior Authorization

Appeals

Evidence-Based Guidelines

Clinical Expertise

Medical Records Review

State Regulations

Quality Assurance

Credentialing

Licensing

Peer-Reviewed Literature

Blank Street

Specialty coffee shop with efficient service

About Blank Street

Blank Street provides a unique coffee shop experience by offering high-quality coffee and food at affordable prices. The company started with a small coffee cart in Brooklyn and has since expanded to major cities like New York, London, Boston, and Washington, D.C. Their product offerings include specialty coffees sourced from around the world and fresh, locally-sourced food. Customers can enjoy a quick yet premium experience, thanks to the efficiency of their small locations that help keep costs down. Blank Street differentiates itself from competitors by focusing on customer convenience through technology, such as their app that allows for ordering ahead, customizing drinks, and participating in loyalty programs. They also prioritize employee satisfaction by paying baristas above-market wages. The goal of Blank Street is to redefine the coffee shop experience by combining quality, affordability, and exceptional service, making it a significant player in the specialty coffee market.

New York City, New YorkHeadquarters

2020Year Founded

$50.6MTotal Funding

EARLY_VCCompany Stage

Food & Agriculture, Consumer SoftwareIndustries

201-500Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Paid Vacation

Paid Sick Leave

Paid Holidays

Parental Leave

Flexible Work Hours

Company Equity

Risks

Rapid expansion may lead to operational inefficiencies and overextension.

Subscription program may not resonate with all customer segments, risking dissatisfaction.

Reliance on outsourced vendors poses risks if supply chain disruptions occur.

Differentiation

Automated espresso machines ensure consistent quality and enhance barista-customer interaction.

Small, cost-effective locations reduce overhead and allow competitive pricing.

Focus on high-quality, clean, and natural products at affordable prices.

Upsides

Rapid expansion into major cities increases brand visibility and market presence.

Subscription model provides steady revenue and enhances customer loyalty.

Partnerships with lifestyle brands boost brand visibility and customer engagement.

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