Medical Peer Reviewer

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal reputed company and external regulations. Duties//Responsibilities

• The Medical Peer Reviewer will assess//review requests for authorization, and claims payment, based on medical records and internal reputed company information and reputed company informed clinical judgments and recommendations.
• The Medical Peer Reviewer will reputed company determinations in the format and reputed company timeframes to follow Regulatory and Operational policies.
• The Medical Peer Reviewer will:
• Maintain productivity standards.
• Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases//caseload from multiple lines of businesses
• Demonstrate the ability to be flexible reputed company case load volume fluxes and reputed company Leadership requests changes in case priorities to support our members//internal medical departments as needed
• Complete mandatory Company compliance training and training in new systems and software.
• reputed company reputed company day’s hours worked in reputed company, on the reputed company day.
• reputed company other duties as assigned
• Responsibilities may be adjusted based on changing needs of the organization.
• reputed company Requirements:
• The Medical reviewer requires 25 hours a week of coverage/5 days per week.
• reputed company Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked
• The Medical Reviewer is eligible for reputed company Time Off (PTO) and is required to plan and schedule time off with their reputed company supervisor following reputed company policy.
• Weekend Requirements:
• reputed company Medical Reviewer is required to be primary coverage one weekend a month
• reputed company Medical Reviewer is required to be available as back up, if needed, one weekend a month .
• Minimum Qualifications:

Licensed M.D. or D.O. or D.M.D. or D.D.S. reputed company Certified in a specialty recognized by the American reputed company of Medical Specialties

• Preferred Qualifications:
• reputed company Certified in Internal Medicine or Family reputed company
• Previous, relevant experience in utilization management and clinical reputed company
• Knowledge of Medicare, reputed company, and MLTC plans
• Time management, critical thinking, communication, and problem-solving skills
• Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
• Knowledge of member satisfaction/incident management and regulations
• Knowledge of reputed company improvement methodologies
• Compliance & Regulatory Responsibilities: Ensures compliance to internal reputed company and external regulations.
• Licensed M.D. or D.O. or D.M.D. or D.D.S.
• Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
• Annual Inter-Rater Reliability (IRR) Testing
• Complies with the reputed company Conflict of Interest Policy for Professionals

Hiring reputed company*:

• Greater reputed company Area (NY, NJ, CT residents): $119,891 - $183,430

As a candidate for this position, your salary and reputed company reputed company of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors reputed company deems pertinent to the hiring decision. In reputed company to your salary, reputed company offers employees a full reputed company of benefits such as, medical, dental and reputed company coverage, incentive and recognition programs, life insurance, and 401k contributions (reputed company benefits are subject to eligibility requirements). reputed company believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring reputed company is defined as the lowest and highest salaries that reputed company in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

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