- Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required. Aids and acts as a resource to Initial Clinical Reviewers.
- Serve as the Physician Clinical Reviewer for Interventional Pain Management, reviewing 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.
- 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.
- Provides clinical rationale for standard and expedited appeals.
- 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.
- 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. May assist the Senior Medical Director in research activities/questions.
- MD/DO/MBBS- Required
- Minimum of five (5) years' experience in the practice of Pain Medicine, post-residency- Preferred
- Current, unrestricted clinical license in medicine or required specialty- Required
- Obtaining and maintaining medical licenses in the state you reside and any required per business needs- Required
- Active Board Certification in Pain Management or Active Board Certification in another specialty and clinical experience in Interventional Pain Management- Required
- Strong clinical, management, communication, and organizational skills- Required
- Energetic and curious with a passion for quality and value in health care- Required
- Computer Proficiency- Required
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Physician Clinical Reviewer - Frankfort, United States - Evolent Health
Description
Your Future Evolves Here
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.
Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.
Join Evolent for the mission. Stay for the culture.
What You'll Be Doing:
As a Physician Clinical Reviewer, Interventional Pain Management, 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:
What You Will Be Doing:
Qualifications - Required and Preferred:
Technical Requirements:
We require that all employees have the following technical capability at their home: High speed Internet over 10 Mbps and specifically for all call center employees, the ability to plug in directly to the home Internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.
Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.If you need reasonable accommodation to access the information provided on this website, please contact (see below) for further assistance.
The expected base salary/wage range for this position is $100-$108/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.
