Physician Advisor - Utilization Review / Care Management

Confidential Company  •  Suffern, NY

5 - 7 years experience  •  Staffing & Recruiting

$250K - $275K
Posted on 09/22/17
Confidential Company
Suffern, NY
5 - 7 years experience
Staffing & Recruiting
$250K - $275K
Posted on 09/22/17


The Utilization Review / Care Management Physician Advisor will:

  • Review all imaging cases in which clinical determinations cannot be made by initial clinical review
  • Discuss determination with requesting physicians or ordering providers, when available within the regulatory timeframe of the request by phone or fax
  • Provide clinical rational for standard and expedited appeals
  • Provide assistance to initial clinical reviewers as needed to discuss cases and problems
  • Participate in daily review of aggregate denials/appeals with the Medical Director, peer, and or the Clinical Review Supervisor
  • Utilize medical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with NIA’s polices/ procedures, as well as URAC and NCQA guidelines
  • Document all communication with medical office staff and/or MD provider is recorded in a timely and accurate manner
  • Participate in on-going training per inter-rater reliability process


  • Board eligibility
  • Graduate from an accredited medical school
  • Current unrestricted MD license to practice medicine  
  • 5-8years of clinical hospital experience
  • Knowledge of CMS and Interqual regulations
  • Strong leadership skills
  • Highly organized


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