The Physician Reviewer plays an essential role in ensuring the quality and appropriateness of healthcare services by conducting thorough medical record reviews and assessments. The Physician Reviewer will evaluate clinical documentation to determine the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. The Physician Reviewer collaborates with healthcare providers, and utilization and case management teams to support decision-making processes related to patient care and reimbursement. By applying clinical expertise and evidence-based guidelines, the Physician Reviewer helps to promote optimal patient outcomes in a cost effective manner. This role requires a strong commitment to accuracy, ethical standards, and continuous learning in a dynamic healthcare environment.
Minimum Qualifications:- Medical degree (MD or DO) from an accredited institution.
- Active and unrestricted Florida medical license.
- Minimum of 3 years clinical experience in a managed care setting.
- Strong knowledge of clinical guidelines, and healthcare regulations.
Preferred Qualifications:- Experience in utilization review, medical auditing, or healthcare quality assurance.
- Familiarity with insurance claims processes and healthcare reimbursement models.
- Proficiency with electronic medical records (EMR) systems and medical review software.
- Experience working in a managed care or health insurance environment.
Responsibilities:- Demonstrates commitment to Our Mission and models ILS Experience Standards of Excellence.
- Review requests for prior authorizations, inpatient and concurrent review, outpatient and procedural requests, and long term care services by analyzing medical records, clinical data, and treatment plans to assess the necessity and appropriateness of healthcare services.
- Apply established clinical guidelines and criteria to evaluate patient care and support utilization management decisions.
- Communicate findings and recommendations clearly to healthcare providers, utilization nurses and case managers.
- Collaborate with interdisciplinary teams and participate in interdisciplinary care team rounds to review care plans, provide clinical guidance, resolve clinical questions and ensure compliance with regulatory and organizational standards.
- Conduct peer-to-peer reviews and reconsiderations with providers requesting a review of denied services or submitting additional information to support a request for services.
- Review grievances and appeals and apply established clinical guidelines and criteria to evaluate patient care and support utilization management decisions.
- Document review outcomes accurately and maintain confidentiality of patient information in accordance with HIPAA regulations.
- Participate in Medicaid Fair Hearings to present the clinical information and guidelines used to make determinations of coverage and medical necessity.
- Performs other duties as assigned.
