Full Time Physician Reviewer - Utilization Management

Description

About us:

Medical Review Institute of America (MRIoA) is the market leader for technology-enabled utilization management (UM) and Clinical Review solutions – touching over 35M lives.  For almost 40 years, MRIoA has perfected the utilization and clinical review process for payers of healthcare costs.  We offer the largest, most extensive review network in the industry. 

Our Physician Reviewer opportunity provides our physicians with the advantage to work from the comfort of their own home.  Utilizing a desktop computer provided for them, they will be responsible for performing clinical utilization management and peer review activities as well as clinical quality management activities.

Medical Directors are paid a salary, and not per case, they are held to strict standards of productivity, and quality, including adequate follow-through and thorough, complete responses.

It is important to note, that due to the short turn-around-time frames of the cases completed by our Medical Directors, (typically within a couple of hours), a set work schedule of 40 hours per week is required.

The Schedule will vary, working 8 or 10 hours a day, between 7am to 7pm MTN TIME ZONE, 7 days a week.  This includes weekend rotations of 4 weekend shifts a month.

Roles:

1. To provide an informed, objective voice to the review of coverage decisions, and provide recommendations for improving the quality of care, and help shape health plan coverage policy to be consistent with current literature and standard of practice.
2. To participate in the clinical quality management activities of the corporation.

Major Responsibilities or Assigned Duties:

1. Perform initial reviews of medical claims.
2. Perform reviews of appealed claims.
3. Perform peer-to-peer consultations, with treating/ordering practitioners/providers in accordance with specific client contractual agreements.
4. Review and adjudicate appeals of pharmacy denials for PBM clients.
5. Participate in committees as requested.
6. Supervise the quality of reviews for accuracy; when necessary, perform a second review for training purposes and evaluate the reviewing physicians’ logic in their analysis of cases.
7. Obtain and store research materials useful in reviews.
8. Keep up to date on coding issues by researching various sources.
9. Keep up to date on general advances in medicine through continuing medical education.
10. Ensure timely communication with the Chief Medical Director regarding issues or unusual circumstances.
11. Conduct periodic consultations with practitioners in the field.
12. Participate in all Company meetings and committees as requested.
13. Develop clinical guidance insights to assist in reducing health care over-utilization.

Qualifications

Qualifications (Skills, Experience, Educational Requirements):

1. MD or DO degree, with a Primary Care specialization (Family Medicine or Internal Medicine only).
2. Less than a 1-year lapse in current direct patient care responsibilities.
3. Ability to easily navigate through several computer programs/portals simultaneously.
4. Current, unrestricted medical license as required for clinical practice in any state of the United States.
5. The ability and desire to obtain additional state licenses as required for the position.  
6. Current Board Certification by a medical specialty board approved by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) is required.
7. Minimum of five years of full-time equivalent experience providing direct clinical care to patients, with less than a 6-month gap in recent direct patient care. 
8. Be credentialed and privileged by the Company's Credentialing Committee.
9. Thorough understanding of the Company’s clients, products, departments, workflows, and applicable regulatory requirements and accreditation standards.

Environment:

Work from home in a dedicated work environment.