Are you an experienced Medical Director/ Physician Reviewer with a desire to excel? If so, then Talent Software Services may have the job for you! Our client is seeking an experienced Medical Director/ Physician Reviewer to work remotely at their company.
Medical Director/ Physician Reviewer
(•Active medical state licensure required for PA, NY, or WV)
The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
•Actively manage projects and/or participate on project teams that require a physician subject matter expert.
•Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
•5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
•Medical Doctor or Doctor of Osteopathic Medicine (DO)
•Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
•Active medical state licensure required for PA, NY, or WV.
•Customer Service
•Telephone Skills
•General Computer Skills
•Clinical Software
•1 year in Medical Management in a Health Insurance Plan;
Medical Director/ Physician Reviewer
(•Active medical state licensure required for PA, NY, or WV)
The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
•Actively manage projects and/or participate on project teams that require a physician subject matter expert.
•Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
•5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
•Medical Doctor or Doctor of Osteopathic Medicine (DO)
•Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
•Active medical state licensure required for PA, NY, or WV.
•Customer Service
•Telephone Skills
•General Computer Skills
•Clinical Software
•1 year in Medical Management in a Health Insurance Plan;
AI Data Engineer 1 in pittsburgh at Unknown Company
This position is listed as full time and able to be worked remotely.