[Hiring] PRN Medical Reviewer-2 @CareMore Health

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description • Conduct prospective, concurrent, and retrospective clinical reviews of medical services to determine medical necessity and appropriateness. • Utilize evidence-based criteria (e.g., MCG, InterQual, CMS guidelines) in evaluating requests for services. • Collaborate with nurses, case managers, and other healthcare professionals in the UM process. • Provide timely peer-to-peer consultations with requesting providers to discuss clinical decisions and alternative care options. • Participate in appeals and grievance processes by reviewing denied cases and providing justification based on medical necessity and standards of care. • Ensure all reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies. • Document decisions clearly and accurately in the appropriate systems. • Identify patterns of inappropriate utilization and collaborate in quality improvement initiatives. • Participate in staff training, UM committee meetings, and policy development as needed. Qualifications • Medical Degree (MD or DO) from an accredited institution. • Board certification in a clinical specialty (e.g., Internal Medicine, Family Medicine, Pediatrics, Psychiatry, etc.). • Active, unrestricted medical license state required. • Minimum of 3–5 years of clinical experience; experience in managed care, utilization review, or insurance industry preferred. • Familiarity with UM guidelines (e.g., MCG, InterQual), Medicare/Medicaid regulations, and health plan operations. • Excellent clinical judgment and decision-making skills. • Strong communication and documentation skills. • Proficient in using electronic medical records (EMRs – Athena a plus), review platforms, and Microsoft Office Suite. Requirements • Experience working in a health plan, insurance company, or third-party administrator (TPA) preferred. • Knowledge of value-based care, population health, and cost containment strategies. • Ability to manage multiple tasks and meet deadlines in a remote or fast-paced environment. Compensation $134.55 to $201.83