Utilization Management Physician (UMP)

Summary

Florida Health Care Plans, a large multi-specialty staff model HMO, is seeking a Utilization Management Physician (UMP). This full-time, remote position requires critical thinking skills, effective communication, and decisive judgement. The ideal candidate will have a working knowledge of the responsibilities listed.

* Review pre-authorization requests, initial clinical review, and concurrent clinical review cases. Review post-service clinical decisions, including claims and appeals.

* Render determinations based on relevant clinical information, medical necessity determined by using evidence-based medicine, nationally recognized criteria (i.e. MCG (formally Milliman), InterQual, Centers for Medicare and Medicaid), FHCP Protocols, and the Member's FHCP Coverage Documents.

* Review clinical criteria and scripts at least annually and update if necessary.

* Assist the CMO in Provider education regarding treatment protocols, treatment options, etc., as appropriate.

* Be available to FHCP UM staff to answer questions regarding cases under review.

* Be available for peer-to-peer discussions of cases under initial or concurrent review either in person, by telephone, or electronically.

* Meet current regulatory standards regarding pre-authorization determinations.

* Be available to discuss urgent cases directly with attending provider.

* For non-certification decisions, specifies the principal reason for the determination not to certify and the clinical rationale for the non-certification.

* Consult with other physicians in medical specialty areas as needed.

* Participate in FHCP committees at the request of the CMO.

Practitioner Requirements Practitioner must meet the following minimum requirements to serve as a Utilization Management Practitioner("UMP) for FHCP:

* MD, DO, or PhD degree from an accredited medical school.

* Licensed to practice medicine in the state of Florida without restriction.

* Board certified in primary specialty preferred.

* Have three (3) to five (5) years of clinical experience.

* Knowledge and experience with managed care health plan and benefits

* Ability to provide medical knowledge to facilitate resolution of complex issues and required decisions.

* Working knowledge of medical policy and application of criteria

* Agree to participate in the Interrater Reliability Tool or such other audit process employed by FHCP to ensure consistent application of medical policy and coverage criteria.

Compensation Details

* Competitive salary

* Bonus opportunity

* 401(K) Tax Deferred Plan

* HMO Health Benefits for provider & eligible dependents

* Group Term Life

* Group Disability

* Malpractice Insurance

* Paid Leave Time

* CME Stipend

* Licenses, Fees & Dues reimbursed.

* Travel Reimbursement

* Relocation Assistance