What are the responsibilities and job description for the Utilization Management Physician (UMP) position at Provider Services?
Summary
Florida Health Care Plans 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
* 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 clinical experience.
* Minimum of three (3) years of Utilization Management 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
•EOE/M/F/Vet/Disabled