Remote Utilization Management Physician Florida

A large multi-specialty staff model HMO, is seeking a Utilization Management Physician (UMP). This full-time, remote position requires critical thinking skills, effective communication, and decisive judgement.

• Review pre-authorization requests, initial clinical review, and concurrent clinical review cases. Review post-service clinical decisions, including claims and appeals
• Render determinations based on relevant clinical information, medical necessity determined by using evidence-based medicine, nationally recognized criteria (i.e. MCG (formally Milliman), Inter Qual, Centers for Medicare and Medicaid), FHCP Protocols, and the Member's FHCP Coverage Documents
• Review clinical criteria and scripts at least annually and update if necessary
• Assist the CMO in Provider education regarding treatment protocols, treatment options, etc., as appropriate
• Be available to staff to answer questions regarding cases under review
• Be available for peer-to-peer discussions of cases under initial or concurrent review either in person, by telephone, or electronically
• Meet current regulatory standards regarding pre-authorization determinations
• Be available to discuss urgent cases directly with attending provider
• For non-certification decisions, specifies the principal reason for the determination not to certify and the clinical rationale for the non-certification
• Consult with other physicians in medical specialty areas as needed
• Participate in committees at the request of the CMO

• MD, DO, or from an accredited medical school
• Licensed to practice medicine in the state of Florida without restriction
• Board certified
• Have three (3) to five (5) years of clinical experience in utilization review
• Knowledge and experience with managed care health plan and benefits
• Ability to provide medical knowledge to facilitate resolution of complex issues and required decisions
• Working knowledge of medical policy and application of criteria
• Agree to participate in the Interrater Reliability Tool or such other audit process to ensure consistent application of medical policy and coverage criteria

• Competitive salary
• Bonus opportunity
• 401(K) Tax Deferred Plan
• HMO Health Benefits for provider & eligible dependents
• Group Term Life
• Group Disability
• Malpractice Insurance
• Paid Leave Time
• CME Stipend
• Licenses, Fees & Dues reimbursed