physician advisor

Internal Reference Number: R1052664 Summary Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: The Physician Advisor optimizes efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. In this role, you will provide assessment and determination of medical necessity in case evaluation and utilization management. The Physician Advisor collaborates with a multidisciplinary team to implement methods and develop care management protocols that optimize the use of BlueCross BlueShield of South Carolina services for all patients while ensuring quality care is provided. Description Location: This position is full-time (40-hours/week) Monday-Friday REMOTE in the United States. Sponsorship: This position is not eligible for sponsorship now or in the future. What You'll Do: 1. Communicates with hospital physicians, care coordination and utilization management (UM) staff to champion best practices for evidence-based care and its documentation. Provides valuable guidance on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management, and compliance with governmental regulations. 2. Performs UM review functions including pre-admission reviews, continues stay reviews, procedure precertifications, post-service reviews, emergency room visit reviews, and individual case management needs. 3. Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion. 4. Keeps abreast of current CMS and MCG evidence-based guidelines to enable UM decisions. Maintains compliance with legal, regulatory and accreditation requirements and payor partner policies. 5. Uses, protects and discloses patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. 6. Serves as medical resource for quality improvement. Functions as liaison to medical community. 7. Acts as resource for providers/internal staff on medical policies. Educates providers on issues concerning medical policies, utilization specifications, and coding/medical necessity issues. 8. Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations. 9. Participates in medical review policy/quality programs and inter-reviewer reliability studies. To Qualify For This Position, You'll Need The Following : 1. Required Education: Medical Doctor (MD) or Osteopathic Doctor (DO) with current license to practice. If Psychiatry Advisor - Doctor of Psychiatry (MD) with current active medical license, without restriction. 2. Required Experience: 3. *8 years-broad clinical experience to include knowledge of utilization and medical review. Experience may include paid training. 4. Required Skills and Abilities: Demonstrated ability to direct multiple strategic projects. Excellent ve bal and written communication skills. Excellent judgment, organizational, customer service, presentation skills. Excellent analytical or critical thinking skills. Knowledge of strategic concepts. Ability to persuade, negotiate, or influence others. 5. Required Software and Tools: Microsoft Office 6. Required Licenses and Certificates: Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty. We Prefer That You Have The Following: 1. Experience with prior authorization review. 2. 2 years-medical data analysis/analytical capability to interpret statistical information. 3. Experience with medical oversight of quality improvement activities. 4. Experience with quality committees or NCQA. 5. Experience with population based disease management or public health initiatives. 6. Experience in medical management or managed care. 7. Demonstrated understanding of Medicare programs. Our Comprehensive Benefits Package Includes The Following : We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. *Subsidized health plans, dental and vision coverage *401k retirement savings plan with company match *Life Insurance *Paid Time Off (PTO) *On-site cafeterias and fitness centers in major locations *Education Assistance *Service Recognition *National discounts to movies, theaters, zoos, theme parks and more What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Pay Range Information: Range Minimum $176,132.00 Range Midpoint $265,574.50 Range Maximum $355,017.00 Pay Transparency Statement: Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and inte