Group Health Medical Director Reviewer

JOB SUMMARY

Dane Street, a certified “Great Place to Work” company is seeking a Physician to provide utilization review services and clinical oversight for the Group Health Department.

This role requires utilizing clinical expertise to review medical records and provide an interpretation of the medical appropriateness of services in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies. Additionally, serve as the clinical lead for the Group Health Department, providing governance to physician reviewers and overseeing ongoing training and quality assurance.

Dane Street’s success relies on individual and team contributions every day. We care for our customers, each other and Dane Street. It is the responsibility for all of us to maintain a positive working environment that promotes client satisfaction and results.

MAJOR DUTIES & RESPONSIBILITIES

• Review all medical records using state-mandated or other nationally recognized evidence-based criteria.
• Ensure clear, concise, and well-supported rationales for determinations.
• Make mandated phone calls.
• Return cases on or before the due date and time.
• Assist with quality assurance of reports prior to submission to clients.
• Maintain proper credentialing, state licenses, and any special certifications
• Utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature for decision-making.
• Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.
• Provide copies of any criteria utilized in a review with the report.
• Other duties & special projects, as assigned and based on business needs.

EDUCATION/CREDENTIALS:

• Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US.

JOB RELEVANT EXPERIENCE:

• Minimum five years of postgraduate experience
• Extensive clinical business background required
• Experience in Utilization Management with criteria review utilizing standard practice guidelines.

JOB RELATED SKILLS/COMPETENCIES:

• Working knowledge of URAC and relevant State and Federal compliance guidelines.
• Excellent communication skills.
• High-level understanding of medical insurance and utilization management.
• Critical thinking
• Ability to manage time efficiently and meet specific deadlines
• Computer literacy and typing skills required

WORKING CONDITIONS/PHYSICAL DEMANDS:

• Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.

WORK FROM HOME TECHNICAL REQUIREMENTS:

• Supply and support their own internet services.
• Maintaining an uninterrupted internet connection is a requirement of all work from home position.

This job description is subject to change at any time.

Benefits

We offer generous Paid Time Off, an excellent benefits package, and a competitive salary. If you want to work in an exciting, fast-paced environment where you can provide meaningful contributions, then we encourage you to apply.