Physician Clinical Reviewer - Rheumatology- REMOTE

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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