Remote Utilization Management Physician Opportunity in 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.

The ideal candidate will have a working knowledge of the responsibilities listed:

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), InterQual, 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

Practitioner Requirements Practitioner must meet the following minimum requirements to serve as a Utilization Management Practitioner(“UMP) for FHCP:

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 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

Additional Benefits:

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