Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)

Job Description:

• Provide expert reviews for cardiovascular cases, serving as a specialty-matched expert reviewer for invasive/interventional cardiology cases.
• Conduct peer-to-peer discussions with treating providers to ensure appropriate, high-value care aligned with clinical guidelines.
• Collaborate with leadership, management, and clinical staff to address complex cases and support decision-making.

Responsibilities:

• Act as a key resource for Initial Clinical Reviewers, offering guidance and expertise to ensure the application of best practices.
• Provides clinical rationale for standard and expedited appeals.
• Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request.