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Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies render coverage determinations
Document clinical review findings actions and outcomes in accordance with policies and regulatory and accreditation requirements
Engage with requesting providers as needed in peer-to-peer discussions
Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
Participate in daily clinical rounds as requested
Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
Communicate and collaborate with other internal partners
Call coverage rotation
Youll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
M.D or D.O.
Active unrestricted license to practice medicine
Board certification in an ABMS specialty
5 years of clinical practice experience after completing residency training
Sound understanding of Evidence Based Medicine (EBM)
Proven solid PC skills specifically using MS Word Outlook and Excel
Ability to participate in call coverage rotation
Preferred Qualifications:
Licensed in AZ CA MA MN or TX
Board certified in family medicine or internal medicine
Experience in utilization and clinical coverage review
Proven excellent oral written and interpersonal communication skills facilitation skills
Proven data analysis and interpretation aptitude
Proven innovative problem-solving skills
Proven excellent presentation skills for both clinical and non-clinical audiences
Employment Type
Full-Time
