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