Job Description
Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals. Discuss cases with physician providers (Peer to Peer).
Key Responsibilities
Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
Discuss cases with physician providers (Peer to Peer)
Apply health plan review hierarchy to member contracts, CMS National & Local Coverage Determinations, Florida Blue medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, documentation, accuracy and quality of review
Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
As necessary, assist nurses and other staff in understanding clinical concepts, the principles behind appropriate utilization review and interpretation and application of benefits and policies
Participate in the development and review of Medical and Pharmacy policies as assigned
Support the organization as a subject matter expert
Perform as lead Medical Director consultant for one sub-category of utilization management
Perform other duties as assigned and needed by the organization
Some after hours and weekend work required
Key Requirements
Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
Utilization management experience
5+ years of clinical experience
Experience working both independently and in a team environment
Exceptional verbal and written communication
Preferred
Medicare UM review experience
Primary Care Specialty physician experience
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
What We Offer
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
Medical, dental, vision, life and global travel health insurance;
Income protection benefits: life insurance, short- and long-term disability programs;
Leave programs to support personal circumstances;
Retirement Savings Plan including employer match;
Paid time off, volunteer time off, 10 holidays and 2 well-being days;
Additional voluntary benefits available; and
A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $220,000 - $357,500
Typical Annualized Hiring Range: $220,000 - $275,000
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.