SyncHealthcare ยท 4 months ago
Clinical Reviewer (MD/DO/Psych-D), Utilization Management- Part-time/Full-time (1099)
United States
Full-time, Part-time
Remote
Mid, Senior Level
5+ years expSyncHealthcare is a healthcare management company focused on improving access and quality care for patients. They are seeking experienced board-certified physicians (MD/DO) and Psych-D to join their Utilization Management Reviewer Panel as independent contractors. The role involves conducting clinical reviews and ensuring services are clinically appropriate and compliant with standards.
Hospital & Health Care
Responsibilities
Conduct physician or psych-D level clinical reviews for prior authorization, concurrent review, retrospective review, and appeals across multiple lines of business
Apply nationally recognized clinical criteria (e.g., InterQual, MCG, ASAM, ABA), health plan policies, and regulatory requirements (CMS, Medicaid, NCQA, URAC)
Render timely clinical determinations consistent with required turnaround times
Participate in peer-to-peer discussions with treating providers to communicate decisions and promote evidence-based care
Review and analyze provider-submitted documentation to assess medical necessity, appropriateness of care, and benefit coverage
Support appeals, grievances, and hearings with defensible, evidence-based clinical rationale
Collaborate with UM nurses, case managers, and multidisciplinary care teams
May serve as a clinical resource for internal teams regarding UM protocols, clinical policies, and specialized care pathways
Ensure strict adherence to HIPAA, privacy, and confidentiality requirements
Contribute to quality improvement initiatives, audits, and training efforts
Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies
Performs other duties as assigned
Comply with all policies and standards
Exhibit sound organizational and excellent communication skills
Qualification
Required
MD or DO degree required or Psych-D degree required
Active, unrestricted U.S. medical/clinical license (multi-state licensure preferred)
Board certification by ABMS or AOA-recognized specialty board or BCBA/BCBA-D required
Active clinical practice required
Minimum of 5 years of clinical practice experience in your specialty
Strong written and verbal communication skills, especially for peer-to-peer discussions and case documentation
Proficiency with electronic medical record systems and UM review platforms
Preferred
At least 1 year of UM, peer review, or managed care experience strongly preferred
Familiarity with evidence-based clinical guidelines and UM criteria (InterQual, MCG, ABA, ASAM)
Multi-state license, preferred
Company
SyncHealthcare
11-50 employees
Funding
Current Stage
Early StageCompany data provided by crunchbase