Cardiology Physician

As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes.

Collaboration Opportunities:

• Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician s input is needed or required. As well as, aids and acts as a resource to Initial Clinical Reviewers.

What You Will Be Doing:

• Serve as the specialty match reviewer in Cardiology cases, that do not initially meet the applicable medical necessity guidelines, as well as other requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.

• Provides clinical rationale for standard and expedited appeals.

• Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request.

• 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 Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (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.

• May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.

• On a requested basis, may function as Medical Director for selecting health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director.

Qualifications - Required and Preferred:

• MD/DO/MBBS Degree

• Current, unrestricted clinical license in medicine or required specialty

• Obtaining and maintaining medical licenses in the state you reside, as well as, other state licensure required per business needs

• Active Board Certification in Cardiology, Vascular Surgery or Adult Congenital Heart Disease

• Strong clinical, management, communication, and organizational skills

• Energetic and curious with a passion for quality and value in health care

• Computer Proficiency

• Minimum of five (5) years experience in the practice of Cardiology is preferred

• Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.

• No history of a major disciplinary or legal action by a state medical board