Physician Clinical Reviewer - Pediatric Neurology - Remote

Overview

Prime Therapeutics is seeking a Physician Clinical Reviewer specializing in Pediatric Neurology to join their utilization management team. This role involves reviewing medical service requests and ensuring compliance with medical necessity guidelines.

In Short

• Key member of the utilization management team.
• Reviews cases that require clinical determinations.
• Communicates with physicians and health plan members.
• Provides clinical rationale for appeals.
• Ensures compliance with URAC and NCQA guidelines.
• Participates in ongoing training and testing.
• Assists Medical Director with research activities.
• May function as Medical Director for select health plans.
• Documents communications accurately.
• Other duties as assigned.

Requirements

• Education: DO, MBBS, or MD required.
• 5+ years of clinical experience required.
• Must be eligible to work in the USA without sponsorship.
• Strong communication skills.
• Ability to operate office equipment.
• Must be able to remain stationary for 50% of the time.
• Occasional lifting required (up to 25 pounds).
• Compliance with security responsibilities and policies.
• Background check may be required.
• Commitment to diversity and inclusion.

Benefits

• Competitive salary based on experience.
• Comprehensive benefits package.
• Opportunities for professional development.
• Supportive work environment.
• Equal opportunity employer.
• Tobacco-Free Workplace.
• Flexible working conditions.
• Encouragement of diverse candidates to apply.
• Reasonable accommodations for applicants with disabilities.
• Access to employee resources for health and wellness.