A key member of the utilization management team and provides a 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 Cardiac cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
- Serve as the special match reviewer in Cardiac cases as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert licensed/board certified in that area.
- Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe 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 in their specialty area.
- Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.
- Ensures documentation of all communications with medical office staff and/or MD providers is recorded in a timely and accurate manner.
- Participates in ongoing training per inter-rater reliability process.
- Assists the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support.
- On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
- On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director.
Other Job Requirements
Doctor of Medicine (MD) degree OR Doctor of Osteopathic Medicine (DO) degree OR Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of United States based internship and residency (and successful completion of United States based fellowship for subspecialists) required.
Current, unrestricted license to practice medicine in one or more states of the United States.
Board Certified by one of the following: American Board of Cardiovascular Medicine (ABCMC).
A licensed Physician practicing as one of the following: Cardiologist.
Cardiology Fellows may be given consideration based on clinical experiences.
Education - Required
DO, MBBS, MD
License and Certifications - Required
DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MBBS - Bachelor of Medicine, Bachelor of Surgery - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician
License and Certifications - Preferred