Utilization Management Physician Reviewer

🕒 2 days ago

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Dane Street

WebsiteLinkedInAll Job Openings

51 - 200 employees

⚕️ Healthcare Insurance

📋 Compliance

🏛️ Government

Healthcare Insurance • Compliance • Government

Dane Street is a national leader in Independent Medical Exams and Reviews, providing objective, compliant, and timely Independent Medical Examinations, Peer Reviews, and other medical reports. With a large network of over 16,000 physicians, the company offers its services across 25,000 locations and 100 specialties, including Workers' Compensation, Auto, Liability, and Disability claims. Dane Street supports Insurance Carriers, Third Party Administrators, Managed Care Organizations, and Federal/State entities with expert medical analyses, helping them make accurate determinations. The company is recognized for its quality, fast turnaround times, and efficient processes, earning accolades like the NCQA Accreditation in Utilization Management and the Great Place to Work certification.

📋 Description

• Review requests for Prior Authorizations and Appeals including medical records and make a medical necessity determination in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies. • Ensure clear, concise, and well-supported rationales for determinations. • Make mandated phone calls. • Provide responses in member friendly language using provided templates. • Return cases on or before the due date and time. • Assist with quality assurance of reports prior to submission to clients. • Maintain proper credentialing, state licenses, and any special certifications • Utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature for decision-making. • Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits. • Provide copies of any criteria utilized in a review with the report. • Other duties & special projects, as assigned and based on business needs.

🎯 Requirements

• Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US. • Minimum five years of postgraduate experience • Extensive clinical business background required • Experience in Utilization Management with criteria review utilizing standard practice guidelines • Medicaid/Medicare experience preferred • Working knowledge of URAC and relevant State and Federal compliance guidelines. • Excellent communication skills. • High-level understanding of medical insurance and utilization management. • Critical thinking • Ability to manage time efficiently and meet specific deadlines • Computer literacy and typing skills required

🏖️ Benefits

• We offer generous Paid Time Off • an excellent benefits package • and a competitive salary