Description
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.
As a Physician Clinical Reviewer you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes.
Collaboration Opportunities
- Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required.
Roles and Responsibilities
- Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.
- Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals.
- Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process 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.
- Aids and acts as a resource to Initial Clinical Reviewers.
- Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.
- May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
- Participates in on-going training per inter-rater reliability process.
Qualifications - Required and Preferred
- MD/DO/MBBS- Required.
- Minimum of five (5) years’ experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years- Preferred.
- Current, unrestricted clinical license in medicine or required specialty- Required.
- Obtaining and maintaining medical licenses in the state you reside- Required.
- Active Board Certification (If a specialty or subspecialty, must also have that BC)-Required.
- Strong clinical, management, communication, and organizational skills-Required.
- Energetic and curious with a passion for quality and value in health care-Required.
- Computer Proficiency-Required.
