The Physician Reviewer serves as a clinical subject matter expert in the Utilization Management (UM) department. This role is responsible for conducting clinical reviews of medical necessity appropriateness of care and service requests based on evidence-based guidelines medical policy and regulatory requirements. The Physician Reviewer collaborates with UM nurses medical directors and other healthcare professionals to ensure appropriate timely and cost-effective care for members. Key Responsibilities Conduct physician-level reviews of prior authorization concurrent review and retrospective review cases across multiple lines of business (e.g. commercial Medicaid Medicare). Apply nationally recognized clinical criteria (e.g. MCG InterQual) internal medical policies and applicable regulations (CMS NCQA URAC) to review determinations. Render clinical decisions in a timely manner consistent with regulatory timeframes and health … Sign In to View