Our client is a leader in utilization management and are using evidence-based approach to leverage their exceptional capabilities, powerful analytics, and acute sensitivity to the challenges and needs of everyone involved across the healthcare continuum. By applying proven talent and leading-edge technology, they harness healthcare's evolving demand and inherent change to realize healthcare innovation and deliver improved results and a positive experience for everyone. Can be based in any state in the USA. We are hiring several physicians for medical management positions who can
- Provide timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
- Review appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated.
- Provide timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions.
- Document all actions related to clinical review sessions and attests to appeal review qualifications as required.
- Maintains files of all reviews as required by law and Health Plans to retrieve data.
- Maintains necessary credentials and immediately informs the organization of any adverse actions relating to medical licenses and/or board certifications.
- Supports the annual review of utilization review criteria.
- Participates in strategic planning for and evaluation of the Care Management process/unit.
- Assists with staff educational training and in-service programs and serves as a clinical resource for the staff.
- an M.D. or D.O. with a current, active, U.S. state medical license and board certified in a specialty recognized by the American Board of Medical Specialties (ABMS)
- minimum 5 years experience in Orthopedics
- board certification in Orthopedics
- Spine Fellowship required
- Must have recent practice experience in direct patient care (within the past 18 months).
- Knowledge of applicable state and federal laws, URAC and NCQA standards a plus, and familiarity with automated processes and computer applications and systems is required.
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