Clinical Peer Reviewer - Utilization & Compliance

Healthfirst; Pennsylvania; Hybrid; USD 122,907 - 188,020; Full time

Benefits offered by this job

Medical, dental and vision coverage

Life insurance

401k contributions

Incentive and recognition programs

Job summary

Healthfirst is seeking a Medical Peer Reviewer based in Pennsylvania to evaluate medical necessity as part of utilization management. The role requires collaboration with various medical departments and demands flexibility in workload. The hiring range is $122,907 to $188,020, depending on experience and qualifications.

The successful candidate will have a licensed medical degree, relevant board certification, and must be proficient in time management and critical thinking skills.

Qualifications

• Licensed medical degree with board certification required.
• Experience in utilization management and clinical practice preferred.
• Understanding of Medicare, Medicaid, and MLTC plans beneficial.

Responsibilities

• Assess requests for authorization and claims payment.
• Collaborate with Utilization Management and Care Management.
• Complete mandatory compliance training.

Skills

Time management

Critical thinking

Communication

Problem-solving

Education

Licensed M.D. or D.O. or D.M.D. or D.D.S.

Board Certified in a specialty

Job description

Healthfirst is seeking a Medical Peer Reviewer based in Pennsylvania to evaluate medical necessity as part of utilization management. The role requires collaboration with various medical departments and demands flexibility in workload. The hiring range is $122,907 to $188,020, depending on experience and qualifications.

The successful candidate will have a licensed medical degree, relevant board certification, and must be proficient in time management and critical thinking skills.