Physician Reviewer - Group Health
New
D
Dane Street, LLCHealthcare
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Required Skills
- Microsoft OfficeGoogle Workspace
Requirements
- MD or DO
- Board-certified in Internal Medicine, Family Medicine, or similar
- Active, unrestricted medical license
- Prior utilization review experience (preferably in a health plan or IRO environment)
- Familiarity with InterQual
- Familiarity with MCG
- Familiarity with CMS guidelines
- Strong clinical judgment
- Strong documentation skills
- Ability to work independently in a high-throughput environment
- Proficiency with standard business tools (e.g., Google Workspace, Microsoft Office)
- Comfortable working across multiple systems (internal platforms and client-specific portals)
- Strong navigation and documentation skills within web-based applications
- Ability to manage multiple systems/screens simultaneously in a high-throughput environment
- Familiarity with Mac operating systems
Responsibilities
- Perform utilization review for preauthorization requests
- Perform utilization review for appeals (first and second level)
- Perform utilization review for independent external reviews
- Perform utilization review for DRG validation and clinical review
- Perform utilization review for benefit and coverage determinations
- Perform utilization review for experimental/Investigational (E/I) review
- Apply evidence-based criteria and guidelines (InterQual, MCG, CMS, LCD/NCD, client-specific policies)
- Produce clear, concise, and defensible clinical rationales
- Maintain high accuracy and consistency across determinations
- Meet or exceed turnaround time (TAT) expectations, including urgent cases
- Participate in peer-to-peer discussions as needed
- Collaborate with QA and operational teams to ensure quality and compliance
- Conduct reviews within internal systems or client-specific platforms
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