The Physician Reviewer is the primary physician reviewer for Utilization Management (UM) cases in our organization. Other duties include advising other physician reviewers and attending daily calls with health plan teams and our local teams assisting with this function and coordinating care for our patients. The position will also participate in Process and Quality improvement in our developing area of Delegated Utilization Management.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
- Provides Delegated UM by covering the specified territories as assigned:
- Establish 2-3 cases a day for each market covered (up to 6 markets); ensures attendance on all health plan and local calls; calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories.
- Advises other physician reviewers.
- Other duties as assigned and modified by manager.
KNOWLEDGE, SKILLS AND ABILITIES:
- Excellent analytical and deductive reasoning skills
- Good judgement and problem-solving skills
- Professional and effective communication skills
- Strong organizational skills
- Written and verbal fluency in English
- Proficient in the use of Microsoft Office products such as Outlook, Excel, Word and PowerPoint
EDUCATION AND EXPERIENCE CRITERIA:
- Graduate from accredited Medical School with a valid, unrestricted license is required
- Completion of Ophthalmology residency
- Board Certification Ophthalmology
- Two (2) years experience in Hospital medicine preferred
- At least one (1) year of utilization review experience preferred
