Reviews 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 acts 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 physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines.
Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
Participates in on-going inter-rater reliability training and testing
Assists the Medical Director and/or VP, Medical Director 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 Director
Other duties as assigned.
Education & Experience
Education Level DO
MBBS
MD
Required Yes
Yes
Yes
Fields of Study
Experience Level 5 years
Required Yes
Details Clinical
Must be eligible to work in the United States without the need for work visa or residency sponsorship.
Additional Qualifications
Requirements
Physical Demands
Must be able to remain in a stationary position 50% of the time. Must be able to "move or traverse"
Must be able to constantly operate a computer and/or other office productivity equipment
Must be able to hear and constantly communicate information and ideas. Must be able to exchange accurate information
Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Potential pay for this position ranges from $90.87 - $154.33 based on experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.
Benefits
Health insuranceRemote work options
Additional Information
At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.
Job Posting Title
Physician Clinical Reviewer - Pediatric Rheumatology- REMOTE Job Description
Key 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 membersand staff whenever a physician`s input is needed or required.
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