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 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 acts 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 review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as URAC and 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 VP of Medical Affairs 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 VP, Medical Affairs.
- Other duties as assigned.
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 or chiropractic in one or more states of the United States.
Board Certified by one of the following: American Board of Medical Specialties (ABMS), American Board of Osteopathic Specialties (ABOS), American Board of Internal Medicine, or American Board of Osteopathic Internal Medicine (ABIM/ABOIM).
Familiarity with the principles and procedures of utilization management as practiced in managed care organizations, experience with cost benefit analysis, quality assurance, and the continuous quality improvement process is desirable.
Education - Required
DO, MBBS, MD
Education - Preferred
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