Utilization Management Physician; UMP

Overview

Utilization Management Physician (UMP) – Provider Services. This is a full-time, remote position in Florida Health Care Plans. 1st shift, Monday–Friday 8am–5pm. This role 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 [formerly Milliman], Inter Qual, 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 Chief Medical Officer (CMO) in provider education regarding treatment protocols and treatment options, 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, specify 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.

• 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.
• Three to five years of clinical experience.
• Knowledge and experience with managed care health plans 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.

• 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