Prime Therapeutics

Medical Reviewer

• Acts as Behavioral Health Medical Director
• Provides timely medical review of service requests
• Discusses determinations with requesting physicians
• Reviews cases in which clinical determinations cannot be made

Physician Clinical Reviewer – Psychiatry

• Reviews cases in which clinical determinations cannot be made
• Discusses determinations with physicians or ordering providers
• Provides clinical rationale for standard and expedited appeals
• Participates in on-going inter-rater reliability training and testing

Physician Clinical Reviewer – Urology

• Reviews cases in which clinical determinations cannot be made
• Discusses determinations with requesting physicians
• Provides clinical rationale for standard and expedited appeals
• Participates in on-going inter-rater reliability training

Physician Clinical Reviewer – Nephrology

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
• Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax.
• Provides clinical rationale for standard and expedited appeals.
• Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
• Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
• Participates in on-going inter-rater reliability training and testing
• Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support.

Physician Clinical Reviewer – Endocrinology

• Review service requests for medical necessity
• Communicate determinations with physicians
• Provide clinical rationale for appeals
• Ensure documentation is accurate and timely
• Participate in training and research related to utilization management

Physician Clinical Reviewer – Pediatric Oncologist

• Reviews cases in which clinical determinations cannot be made
• Discusses determinations with requesting physicians
• Provides clinical rationale for appeals
• Assists initial clinical reviewers as needed

Physician Clinical Reviewer – Pediatric Gastroenterology

• Review medical service requests for adherence to medical necessity guidelines
• Interact with physicians and health plan members as needed
• Ensure accurate documentation of all communications
• Assist in training of initial clinical reviewers

Physician Clinical Reviewer – Dermatology

• Review service requests for medical necessity
• Interact with physicians and other healthcare professionals
• Ensure compliance with URAC and NCQA guidelines
• Document communications with medical staff
• Participate in ongoing training and testing

Physician Clinical Reviewer – Ophthalmology

Business Analyst

• Execute independently on medium sized projects or as part of a team of BAs on large sized or complex projects
• Define and validate business needs with project team
• Participate in stakeholder analysis and identify subject matter experts needed for work effort
• Assess capability gaps, determine solution options and approach, and define solution scope
• Plan overall business analysis approach and activities for projects including user acceptance testing

Senior Business Analyst – Idaho Medicaid

• Reviews cases for medical necessity guidelines
• Discusses determinations with physicians when available
• Provides clinical rationale for appeals
• Ensures documentation of communications is accurate and timely
• Assists Initial Clinical Reviewers as needed

Physician Clinical Reviewer – Allergy/Immunology

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer
• Discusses determinations with requesting physicians
• Provides clinical rationale for standard and expedited appeals
• Utilizes medical/clinical review guidelines for consistency
• Ensures documentation of all communications is recorded
• Participates in ongoing training and testing
• Assists Medical Director in research activities/questions

Physician Clinical Reviewer – Oncologist

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
• Discusses determinations with requesting physicians or ordering providers.
• Provides clinical rationale for standard and expedited appeals.
• Provides assistance and acts as a resource to Initial Clinical Reviewers as needed.
• Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process.
• Ensures documentation of all communications with medical office staff and/or physician/provider is recorded.

Physician Clinical Reviewer – Pediatric Neurology

• Reviews cases for medical necessity
• Discusses determinations with physicians
• Provides clinical rationale for appeals
• Assists Initial Clinical Reviewers
• Ensures timely communication documentation
• Participates in ongoing training
• Assists with research related to Utilization Management

Physician Clinical Reviewer – Gastroenterology

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
• Discusses determinations with requesting physicians or ordering providers.
• Provides clinical rationale for standard and expedited appeals.
• Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process.

Physician Clinical Reviewer – Pediatric Rheumatology

• Review cases for medical necessity guidelines
• Discuss determinations with physicians
• Provide clinical rationale for appeals
• Assist Initial Clinical Reviewers in case discussions