Physician Clinical Reviewer- GI- REMOTE

Description

• 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 act 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 so as 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 provider is recorded in a timely and accurate manner.
• Participates in on-going training per inter-rater reliability process.
• Assists the VP, 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.

Responsibilities

Medicare Part D experience preferred.

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.

Work Experience

Work Experience - Required :

Clinical

Work Experience - Preferred :

Education

Education - Required :

DO, MBBS, MD

Education - Preferred :

Certifications

Certifications - Required :

DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician - Physician, MBBS - Bachelor of Medicine, Bachelor of Surgery - Physician - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician - Physician

Certifications - Preferred :

Potential pay for this position ranges from $71.31 - $128.34 based on experience and skills. Pay range may vary by 8% depending on applicant location.

To review our Benefits, Incentives and Additional Compensation, visit our and click on the "Benefits at a glance" button for more detail.

Positions will be posted for a minimum of five consecutive workdays.