Physician Clinical Reviewer - Rheumatology- REMOTE

Physician Clinical Reviewer – Rheumatology (REMOTE) Key member of the utilization management team, providing timely medical review of service requests that do not initially meet applicable medical necessity guidelines. Routinely interacts with physicians, leadership, management staff, other Physician Clinical Reviewers (PCR), and health plan members to obtain physician input as needed. Responsibilities Reviews cases where clinical determinations cannot be made by the Initial Clinical Reviewer. Discusses determinations with requesting physicians or ordering providers, within the regulatory time frame by phone or fax. Provides clinical rationale for standard and expedited appeals. Assists and serves as a resource to Initial Clinical Reviewers in discussing cases and problems. Utilizes medical/clinical review guidelines and parameters to ensure consistency and compliance with Prime’s policies, URAC and NCQA guidelines. Documents all communications with medical office staff and/or physicians in a timely and accurate manner. Participates in ongoing inter-rater reliability training and testing. Assists the Medical Director and/or VP, Medical Director in research activities related to utilization management. On request, reviews appeal cases and attends hearings for utilization management decisions. On request, may function as Medical Director for select health plans or regions, in collaboration with the VP, Medical Director. Other duties as assigned. Education & Experience Education Level (required): DO, MBBS, or MD. Experience: Minimum 5 years of clinical experience (required). Must be eligible to work in the United States without a work visa or sponsorship. Additional Qualifications None specified. Physical Demands Remain in a stationary position 50% of the time. Operate a computer or other office equipment continuously. Communicate information clearly and accurately. Lifting or moving up to 10 pounds occasionally; up to 25 pounds occasionally. Benefits and Compensation Potential pay ranges from $90.87 to $154.33 per hour, based on experience and skills. Benefits information is available on the company’s benefits page. Equal Opportunity & Diversity Statement Prime Therapeutics is a proud equal‑opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome applicants of diverse backgrounds and those with arrest or conviction records, as well as persons requiring reasonable accommodations. Prime Therapeutics is a tobacco‑free workplace employer. Reasonable Accommodation If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at View phone number on click.appcast.io or email View email address on click.appcast.io. #J-18808-Ljbffr