Clinical Peer Reviewer - Utilization & Compliance

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401k contributions

Job summary

Healthfirst is seeking a Medical Peer Reviewer to consult on medical necessity in utilization management and ensure compliance with internal and external regulations. The role involves assessing requests for authorization and collaborating with various departments to manage clinical judgements efficiently.

The position requires a Licensed M.D. or D.O. with Board Certification. Healthfirst offers a competitive salary range of $122,907 - $188,020 and a comprehensive benefits package including medical, dental, and vision coverage.

Qualifications

• Licensed M.D. or D.O. or D.M.D. or D.D.S. required.
• Board Certified in a specialty recognized by the American Board of Medical Specialties.
• Previous experience in utilization management and clinical practice encouraged.

Responsibilities

• Assess/review requests for authorization and claims payment based on medical records.
• Render determinations in accordance with Regulatory and Operational policies.
• Collaborate with Utilization Management and Care Management teams.

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 recognized by the American Board of Medical Specialties

Job description

Healthfirst is seeking a Medical Peer Reviewer to consult on medical necessity in utilization management and ensure compliance with internal and external regulations. The role involves assessing requests for authorization and collaborating with various departments to manage clinical judgements efficiently.

The position requires a Licensed M.D. or D.O. with Board Certification. Healthfirst offers a competitive salary range of $122,907 - $188,020 and a comprehensive benefits package including medical, dental, and vision coverage.