Dane Street
This role involves providing utilization review services by reviewing medical records and determining the medical appropriateness of services in compliance with state regulations, evidence-based guidelines, and client-specific policies. The physician will ensure clear rationales for determinations, make mandated phone calls, and assist with quality assurance of reports.
Key Responsibilities
- • Review requests for Prior Authorizations and Appeals including medical records and make a medical necessity determination in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
- • Ensure clear, concise, and well-supported rationales for determinations
- • Make mandated phone calls
- • Provide responses in member friendly language using provided templates
- • 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
Required
- • Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US
- • Minimum five years of postgraduate experience
- • Extensive clinical business background required
- • Experience in Utilization Management with criteria review utilizing standard practice guidelines
- • 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
Preferred
- • Medicaid/Medicare experience preferred
Benefits & Perks
- • Generous Paid Time Off
- • An excellent benefits package
- • A competitive salary
Company Overview
Industry: Healthcare Technology
Company Size: 500-1,000 employees
Founded: 2015
Headquarters: San Francisco, CA
Company Links
Key Contacts
Contact information not available
About the Company
Leading healthcare technology company focused on improving patient outcomes through innovative digital solutions. We're transforming the way healthcare is delivered with cutting-edge technology and data-driven insights. Our platform serves over 10,000 healthcare professionals and has processed millions of patient interactions.
Recent News & Updates
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.
Dane Street's success relies on individual and team contributions every day. We care for our customers, each other, and Dane Street
Major Duties & Responsibilities
- Review requests for Prior Authorizations and Appeals including medical records and make a medical necessity determination in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
- Ensure clear, concise, and well-supported rationales for determinations
- Make mandated phone calls
- Provide responses in member friendly language using provided templates
- 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
- Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US
- Minimum five years of postgraduate experience
- Extensive clinical business background required
- Experience in Utilization Management with criteria review utilizing standard practice guidelines
- Medicaid/Medicare experience preferred
- 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
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.
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