Physician - Utilization Review

Company: Dane Street (Certified "Great Place to Work") Department: Group Health Employment Type: Full-time Location Type: Remote Workplace: Remote Language: English Published: 2024-04-09

Position Overview

Dane Street is seeking a Physician to provide utilization review services for the Group Health Department. This role involves utilizing clinical expertise to review medical records, interpret the medical appropriateness of services, and ensure compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.

Responsibilities

• Review Prior Authorization and Appeal requests, including medical records, to make medical necessity determinations.
• Ensure determinations comply with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
• Provide clear, concise, and well-supported rationales for determinations.
• Make mandated phone calls and provide responses in member-friendly language using provided templates.
• Return cases on or before the due date and time.
• Assist with quality assurance of reports prior to submission to clients.
• Maintain proper credentialing, state licenses, and any special certifications.
• Utilize current criteria and resources such as national, state, and professional association guidelines, and peer-reviewed literature for decision-making.
• Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.
• Provide copies of any criteria utilized in a review with the report.
• Perform other duties and special projects as assigned and based on business needs.

Requirements

Education/Credentials:

• Board Certified M.D. or D.O.
• Current, unrestricted clinical license in any state in the US.

Job Relevant Experience:

• Minimum five years of postgraduate experience.
• Extensive clinical business background required.
• Experience in Utilization Management with criteria review utilizing standard practice guidelines.
• Medicaid/Medicare experience preferred.

Job Related Skills/Competencies:

• Working knowledge of URAC and relevant State and Federal compliance guidelines.
• Excellent communication skills.
• High-level understanding of medical insurance and utilization management.
• Critical thinking skills.
• Ability to manage time efficiently and meet specific deadlines.
• Computer literacy and typing skills required.

Benefits

Dane Street offers generous Paid Time Off, an excellent benefits package, and a competitive salary. We encourage you to apply if you want to work in an exciting, fast-paced environment where you can provide meaningful contributions.