This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards.The incumbent reviews escalated cases electronically and using medical policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service.Depending on the nature of the case, telephonic peer to peer discussions may be required.The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times.
In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management.They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure.Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.
Responsibilities:
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
Participate in protocol and guidelines development to ensure consistency in the review process.
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
Other duties as assigned.
Required Qualifications:
Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
Active medical state licensure required for PA, NY, or WV.
Critical Thinking
Case Management
Customer Service
Oral & Written Communication Skills
Collaboration
Listening
Telephone Skills
General Computer Skills
Clinical Software
Managed Care
Preferred Qualifications:
Master's Degree in Business Administration/Management or Public Health
1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry
Experience with ClientG or InterQual
Medical Director
This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards.The incumbent reviews escalated cases electronically and using medical policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service.Depending on the nature of the case, telephonic peer to peer discussions may be required.The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times.
In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management.They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure.Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.
Responsibilities:
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
Participate in protocol and guidelines development to ensure consistency in the review process.
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
Other duties as assigned.
Required Qualifications:
Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
Active medical state licensure required for PA, NY, or WV.
Critical Thinking
Case Management
Customer Service
Oral & Written Communication Skills
Collaboration
Listening
Telephone Skills
General Computer Skills
Clinical Software
Managed Care
Preferred Qualifications:
Master's Degree in Business Administration/Management or Public Health
1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry
Experience with ClientG or InterQual
What You'll Do
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
Participate in protocol and guidelines development to ensure consistency in the review process.
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
Other duties as assigned.
Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
