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**Position can be based remotely from any Florida location**

Job duties include but are not limited to
• Perform all types of UM reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
• Discuss cases with physician providers (Peer to Peer)
• Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
• Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
• Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
• Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
• As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
• Participate in the development and review of Medical and Pharmacy policies as assigned
• Support the organization as a subject matter expert
• Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
• Perform other duties as assigned and needed by the organization

Job Requirements:
• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine or ability to obtain Florida Medical License
• Board Certification by American Board of Medical Specialties
• 3+ years of clinical experience
• Experience working in a dynamic, fast-paced environment
• Experience working both independently and in a team environment
• Exceptional verbal and written communication

• Physician reviewer or utilization management experience
• Primary Care Specialty physician experience

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