Utilization Management Physician

Overview

The Utilization Management Physician will be responsible for providing thorough and accurate reviews of utilization management cases to ensure the appropriate use of medical resources while continuing to hold high standards of patient care. The position will involve collaborating closely with both the Medical Director, other team members, and clients to conduct reviews with a high level of accuracy and efficiency. This collaboration ensures that reviews are thorough, well documented, and align with established medical guidelines and standards.

Responsibilities

• Perform utilization management reviews in an efficient and timely manner, ensuring each review is completed with careful attention to detail while maintaining high quality work.
• Review appeals or complaints that relate to medical review decisions by conducting a thorough assessment of all medical records, treatment plans, and other supporting documents from healthcare providers.
• Collaborate with the Medical Director and Senior Management to ensure effective coordination of the delivery of services to clients.
• Communicate with client Medical Directors and other stakeholders regarding the utilization management process; provide detailed explanation of review outcomes, address questions and concerns and ensure all parties are aware of any changes or updates in the process.
• Participate in the quality improvement of all steps in the review process.
• Act as a medical resource and provide guidance to Pharmacists and other team members regarding clinical questions.
• Communicate clearly and professionally with clients at regular meetings regarding quality and production.
• Audit cases and provide quality feedback as needed.
• Perform all other duties as assigned by management.

Qualifications

• Must have a Board Certification in an ABMS or AOA-recognized specialty required if an MD or DO. Current active, unrestricted license to practice medicine required.
• Ability to provide clinical guidance regarding the quality and/or clinical aspects of reviews and, when appropriate, directly communicates with reviewers, staff, and/or clients.
• Ability to travel as required.
• Ability to interact with clients as needed, either independently or as a participating member of a group discussion between service and client, regarding the clinical quality aspects of the medical reviews.
• Must be able to review cases and data thoroughly to ensure that all necessary information meets quality standards.
• Must have strong knowledge of medical terminology and procedures, which may include utilization reviews, quality-assurance services compliance, and claims analysis.
• Must have knowledge of federal and/or state legislative mandates (ERISA and/or state law).
• Must be able to work well under pressure and or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Must be able to maintain confidentiality.
• Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.

LANGUAGE/COMMUNICATION SKILLS

• Ability to read, analyze and interpret common correspondence, medical records, and documents.
• Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar.
• Ability to respond appropriately and professionally to all inquiries or complaints from clients, regulatory agencies, upper management, and/or members of the business community.
• Ability to effectively present information one-on-one, in small groups, and/or to clients or vendors of the company.

Education and/or ExperienceMD, DO, or DPM degree required. Current, active unrestricted license to practice medicine required.Minimum of five years of experience in medical practice required.

Certificates, Licenses, RegistrationsBoard Certification in an ABMS or AOA-recognized specialty required if an MD or DO. Current active,unrestricted license to practice medicine required.

ABOUT US

ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

ExamWorks, LLC is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans

ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.