Magellan Health is the leader in managing complex population health, concentrating on all areas across healthcare and pharmaceutical management.
At Magellan Health, 10,000 people wake up every day determined to help our members. We do this by connecting behavioral, physical, pharmacy and social needs into a complete picture of care that’s personalized, coordinated and cost-effective. By turning fragmented care into focused care, we empower 1 in 10 Americans to lead healthier, more vibrant lives.
Mar 22, 2022
Magellan Health Remote
Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required. Directs daily involvement in the following utilization management functions: Reviews all 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 act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems. Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD...