Physician Clinical Reviewer - Rheumatology- REMOTE
Himalayas · 4 दिन पहले
जॉब विवरण
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 - 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
Responsibilities Physician Clinical Reviewer – Job Description Responsibilities 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
