Physician Reviewer Utilization Management
Job Summary
The Physician Reviewer determines the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information. This role requires applying evidence-based guidelines to ensure quality care and accurate decision-making. The position is remote and involves occasional peer-to-peer discussions with treating providers.
Responsibilities
- Perform clinical medical reviews
- Apply evidence-based guidelines
- Document clinical decisions
- Conduct peer-to-peer provider discussions
Required Skills
- Board-certified MD or DO
- Active license in FL, NC, AZ or IMLC
- 6+ years clinical practice
- Utilization review experience preferred
Job Details
Job Description:
- Determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.
- Hours: 8am - 5pm in your local time zone.
- Call rotation: 1 weekend every 16 weeks.
- Report to the Associate Medical Director, Utilization Management.
Responsibilities:
- Provide timely medical reviews that meet stringent quality parameters.
- Provide clinical determinations based on evidence-based criteria and internal guidelines.
- Clearly and accurately document all communication and decision-making in workflow tools.
- Use correct templates for documenting decisions during case review.
- Meet the appropriate turn-around times for clinical reviews.
- Receive and review escalated reviews.
- Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and explain review outcome decisions.
- Compliance with all applicable laws and regulations.
- Other duties as assigned.
Requirements:
- Board certification as an MD or DO.
- Licensed in one of these states: FL, NC, AZ OR possess an active Interstate Medical Licensure Compact (IMLC).
- 6+ years of clinical practice.
Bonus points:
- Licensure in multiple Oscar states.
- 1+ years of utilization review experience in a managed care plan (health care industry).
- BC in Cardiology, Radiation/Oncology, or Neurology.
- Experience with care management within the health insurance industry.
- Willing and able to obtain additional state licensure as needed.
Benefits:
- Eligible for employee benefits including medical, dental, and vision.
- Participation in Oscar's unlimited vacation.
- Annual performance bonuses.
- 11 paid holidays, paid sick time, paid parental leave, 401(k) plan, life and disability insurance.