Physician Clinical Reviewer- Remote Hawaii
Company: Magellan Health
Posted on: July 1, 2020
[3:04 PM] Joseph, Elizabeth
Candidates who are currently living in and actively licensed in the
state of Hawaii are strongly preferred. Key member of the
utilization management team, and provides timely medical review of
service requests that do not initially meet the applicable medical
necessity guidelines. Routinely interacts with physicians,
leadership and management staff, other Physician Clinical Reviewers
(PCR), and health plan members and staff whenever a physician`s
input is needed or required.Directs daily involvement in the
following utilization management functions:
- Reviews all cases in which clinical determinations cannot be
made by the Initial Clinical Reviewer.
- Discusses determinations with requesting physicians or ordering
providers, when available, within the regulatory timeframe of the
request by phone or fax.
- Provides clinical rationale for standard and expedited
- Provides assistance and act as a resource to Initial Clinical
Reviewers as needed to discuss cases and problems.
- Utilizes medical/clinical review guidelines and parameters to
assure consistency in the MD review process so as to reflect
appropriate utilization and compliance with SBU`s
policies/procedures, as well as URAC and NCQA guidelines.
- Ensures documentation of all communications with medical office
staff and/or MD provider is recorded in a timely and accurate
- Participates in on-going training per inter-rater reliability
- Assists the Senior Medical Director in research
activities/questions related to the Utilization Management process,
interpretation, guidelines and/or system support.
- On a requested basis, reviews appeal cases and/or attends
hearings for discussion of utilization management decisions.
- On a requested basis, may function as Medical Director for
select health plans or regions, assuming overall accountability for
utilization management while working in conjunction with the Senior
General Job Information
TitlePhysician Clinical Reviewer- Remote HawaiiGrade33Job
FamilyClinical Services GroupCountryUnited States of AmericaFLSA
StatusUnited States of America (Non-Exempt)Recruiting Start
Date12/13/2019Date Requisition Created12/13/2019Work
ExperienceClinicalEducationMD (Required)License and Certifications
- RequiredDO - Physician, State Licensure and Board Certified (ABMS
or Specialty Board) - Physician, MD - Physician, State Licensure
and Board Certified (ABMS or Specialty Board) - PhysicianLicense
and Certifications - Preferred
Other Job Requirements
- Familiarity with the principles and procedures of utilization
management as practiced in managed care organizations, experience
with cost benefit analysis, quality assurance and the continuous
quality improvement process is desirable.
- Current, unrestricted license to practice medicine or
chiropractic in one or more states of the United States.
- Board Certified by one of the following: the American Board of
Physical and Rehabilitation Medicine (ABPRM), American Board of
Medical Specialties (ABMS), American Board of Nuclear Medicine
(ABNM), American Board of Cardiovascular Medicine (ABCMC), American
Board of Anesthesiology (ABA), American Board of Osteopathic
Specialties (ABOS), American Board of Internal Medicine or American
Board of Osteopathic Internal Medicine (ABIM/ABOIM).
- A licensed Physician practicing as one of the following:
Anesthesiologist, Cardiologist, Emergency Medicine,
Gastroenterologist, Neurologist, Oncologist, Orthopedic Surgeon,
Otolaryngologist, Pain Management, Radiologist or Urologist.
- Cardiology Fellows may be given consideration based on clinical
Magellan Health Services is proud to be an Equal Opportunity
Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every
employee must understand, comply and attest to the security
responsibilities and security controls unique to their
Keywords: Magellan Health, Honolulu , Physician Clinical Reviewer- Remote Hawaii, Healthcare , Honolulu, Hawaii
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