Physician Reviewer - Utilization Management
Core
Determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.
Role type
Senior physician utilization management reviewer
Builds
Clinical determinations for health insurance coverage decisions
Domain
Health insurance / Utilization management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Board certification (MD/DO), clinical acumen, evidence-based criteria application, peer-to-peer discussion, documentation compliance, state licensure
Preferred skills
Multiple state licensure, managed care plan experience, specialty board certification (Cardiology, Radiation/Oncology, Neurology), care management experience
Technologies
Oscar workflow tools
Responsibilities
Provide timely medical reviews meeting quality parameters, conduct peer-to-peer discussions with treating providers, document decisions clearly for member reference, meet turn-around times for clinical reviews, review escalated cases, comply with applicable laws and regulations
Seniority
Senior, hands-on IC