Medical Peer Reviewer

Duties/Responsibilities:

The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.

The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies.

The Medical Peer Reviewer will:

Maintain productivity standards.

Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses

Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed

Complete mandatory Company compliance training and training in new systems and software.

Enter each days hours worked in Workday, on the same day.

Perform other duties as assigned

Responsibilities may be adjusted based on changing needs of the organization.

Weekday Requirements:

The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage

The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday.

Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked

The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy.

Weekend Requirements:

Each Medical Reviewer is required to be primary coverage one weekend a month

Each Medical Reviewer is required to be available as back up, if needed, one weekend a month

Dental Reviewers have a fixed schedule

Minimum Qualifications:

Licensed M.D. or D.O. or D.M.D. or D.D.S.

Board Certified in a specialty recognized by the American Board of Medical Specialties

Preferred Qualifications:

Board Certified in Internal Medicine , Family Practice, Emergency Medicine

Previous, relevant experience in utilization management and clinical practice

Knowledge of Medicare, Medicaid, and MLTC plans

Time management, critical thinking, communication, and problem-solving skills

Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies

Knowledge of member satisfaction/incident management and regulations

Knowledge of quality improvement methodologies

Compliance & Regulatory Responsibilities : Ensures compliance to internal Healthfirst and external regulations.

Licensed M.D. or D.O. or D.M.D. or D.D.S.

Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades

Annual Inter-Rater Reliability (IRR) Testing

Complies with the Healthfirst Conflict of Interest Policy for Professionals

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.