Physician Clinical Reviewer – Psychiatry

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🔥 1 minute ago

🇺🇸 United States – Remote

💵 $90 - $154 / hour

⏱ Part Time

🟢 Junior

🔍🏥 Medical Reviewer

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Prime Therapeutics

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1998

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Prime Therapeutics is a trusted pharmacy solutions provider dedicated to transforming health care through innovation and transparency. The company offers a wide range of services including clinical solutions for improved member outcomes, drug access and affordability, specialty drug management, and condition management for chronic health issues. With over 7,000 employees, Prime Therapeutics aims to challenge norms in the pharmacy industry, providing exceptional experiences and simplifying the complex for millions across the nation. Their mission goes beyond profit, focusing on creating transformative impacts with long-term solutions, utilizing modern technology and holistic approaches in specialty pharmacy management. Owned by mission-driven partners, Prime Therapeutics emphasizes true transparency and conflict-free service, fostering a culture of care and shared purpose in health care.

📋 Description

• Review cases in which clinical determinations cannot be made by Initial Clinical Reviewers • Discuss determinations with requesting physicians or ordering providers by phone or fax within regulatory time frames • Provide clinical rationale for standard and expedited appeals • Assist and act as a resource to Initial Clinical Reviewers • Apply medical/clinical review guidelines and parameters to ensure consistency, appropriate utilization, and compliance with Prime policies, URAC, and NCQA guidelines • Document communications with medical office staff and physicians/providers accurately and timely • Participate in ongoing inter-rater reliability training and testing • Assist Medical Directors in utilization management research activities and questions • Review appeal cases and/or attend hearings when requested • Potentially function as Medical Director for select health plans or regions when requested • Perform other assigned duties

🎯 Requirements

• Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or international MBBS degree with successful completion of a United States-based internship and residency required • Successful completion of a United States-based fellowship required for subspecialists • Current, unrestricted license to practice medicine in one or more United States states • Board certification by ABMS, ABOS, ABIM, or ABOIM • 1 year of work experience in clinical review • Must be eligible to work in the United States without work visa or residency sponsorship • Familiarity with utilization management principles and procedures in managed care organizations • Preferred: Medicare Part D experience • Preferred: Experience with cost-benefit analysis, quality assurance, and continuous quality improvement • Must comply with job-specific security responsibilities, controls, legal, regulatory, contractual, and internal policy requirements • Must be able to perform essential job functions; reasonable accommodations available when requested

🏖️ Benefits

• Benefits, incentives and additional compensation are available; the posting directs applicants to Prime's Benefits Page for details • Equal opportunity and affirmative action employer • Reasonable accommodations for applicants with disabilities • Tobacco-Free Workplace