Physician

Overview

• Serve as a Physician in a leading healthcare organization, focusing on utilization management and evidence-based clinical reviews.
• Conduct medical appropriateness reviews for inpatient, outpatient, and pharmacy services using established clinical guidelines.
• Work remotely with occasional travel for team meetings and professional development events.
• Participate in call rotations to ensure comprehensive coverage and support for healthcare services.
• Collaborate with multidisciplinary teams to enhance service quality and member-focused healthcare solutions.
• Utilize advanced clinical expertise to ensure compliance with industry standards and regulations.
• Engage in professional development opportunities to expand licensure and expertise in the healthcare domain.
• Contribute to a mission-driven organization dedicated to improving healthcare outcomes for members.

Key Responsibilities & Duties

• Perform timely medical reviews adhering to stringent quality parameters and evidence-based criteria.
• Document clinical decisions clearly and accurately using designated workflow tools and templates.
• Conduct peer-to-peer discussions with providers to clarify clinical information and review outcomes.
• Ensure compliance with applicable laws, regulations, and organizational policies in all clinical reviews.
• Participate in escalated reviews and provide expert clinical determinations as needed.
• Collaborate with internal teams to improve care management processes and healthcare outcomes.
• Support organizational initiatives through active participation in meetings and projects.
• Maintain a high level of professionalism and commitment to patient-centered care in all interactions.

Job Requirements

• Doctor of Medicine (MD) degree with active board certification in a relevant specialty.
• Licensure in FL or NC, or eligibility for Interstate Medical Licensure Compact (IMLCC).
• Minimum of 6 years clinical practice experience and 1 year utilization review experience.
• Proficiency in evidence-based clinical guidelines and managed care principles.
• Strong documentation skills with attention to detail and clarity in clinical reviews.
• Ability to engage in peer-to-peer discussions and provide constructive feedback to providers.
• Willingness to obtain additional state licensure as required for the role.
• Experience in care management within the health insurance industry is highly desirable.