[Hiring] PRN Medical Reviewer-2 @CareMore Health

Role Description

• Conduct prospective, concurrent, and retrospective clinical reviews of medical services to determine medical necessity and appropriateness.
• Utilize evidence-based criteria (e.g., MCG, InterQual, CMS guidelines) in evaluating requests for services.
• Collaborate with nurses, case managers, and other healthcare professionals in the UM process.
• Provide timely peer-to-peer consultations with requesting providers to discuss clinical decisions and alternative care options.
• Participate in appeals and grievance processes by reviewing denied cases and providing justification based on medical necessity and standards of care.
• Ensure all reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies.
• Document decisions clearly and accurately in the appropriate systems.
• Identify patterns of inappropriate utilization and collaborate in quality improvement initiatives.
• Participate in staff training, UM committee meetings, and policy development as needed.

Qualifications

• Medical Degree (MD or DO) from an accredited institution.
• Board certification in a clinical specialty (e.g., Internal Medicine, Family Medicine, Pediatrics, Psychiatry, etc.).
• Active, unrestricted medical license state required.
• Minimum of 3–5 years of clinical experience; experience in managed care, utilization review, or insurance industry preferred.
• Familiarity with UM guidelines (e.g., MCG, InterQual), Medicare/Medicaid regulations, and health plan operations.
• Excellent clinical judgment and decision-making skills.
• Strong communication and documentation skills.
• Proficient in using electronic medical records (EMRs – Athena a plus), review platforms, and Microsoft Office Suite.

Requirements

• Experience working in a health plan, insurance company, or third-party administrator (TPA) preferred.
• Knowledge of value-based care, population health, and cost containment strategies.
• Ability to manage multiple tasks and meet deadlines in a remote or fast-paced environment.

Compensation

$134.55 to $201.83