REMOTE Physician Clinical Reviewer-Internal Medicine

Job Description

Job Description

As a FMD, Radiology, 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.

What You Will Be Doing:

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

• Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals.

• 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.

• Aids and acts as a resource to Initial Clinical Reviewers.

• Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.

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

• Participates in on-going training per inter-rater reliability process.

Qualifications:

• MD/DO/MBBS

• Minimum of five (5) years’ experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years is preferred

• Current, unrestricted clinical home state license in medicine or required specialty-

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

• Active Board Certification by an accredited organization

• Strong clinical, management, communication, and organizational skills

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

• Computer Proficiency

• 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