Description

Cardiovascular Utilization Management Reviewer

Are you ready to make a meaningful impact on patient care in a non-clinical setting? Join our Utilization Management team as a Field Medical Director, Cardiovascular Specialist and use your expertise in interventional cardiology to help ensure the delivery of high-value, evidence-based case reviews. Enjoy improved work-life balance while contributing to better health outcomes in an environment that fosters collaboration, continuous learning, and impactful peer-to-peer discussions. 

What We Offer:

•          A meaningful way to contribute to patient care beyond the clinical setting.
•          Opportunities for collaboration with a dynamic team of physicians, leaders, and clinical professionals.
•          A role that values innovation, continuous improvement, and clinical excellence.
•          This position is 100% Remote and can be completed from any state. Multiple opportunities for a flexible schedule and both part-time and full-time options available. 

What You Will Be Doing:

•          Serve as the specialty match reviewer in Cardiology cases, that do not initially meet the applicable medical necessity guidelines, as well as other requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.
•          Provides clinical rationale for standard and expedited appeals.
•          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.
•         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.
•          May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
•          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.

Qualifications :

•          MD/DO/MBBS Degree
•          Current, unrestricted clinical license in medicine or required specialty
•          Obtaining and maintaining medical licenses in the state you reside, as well as, other state licensure required per business needs
•          Active Board Certification in Cardiology
•          Strong clinical, management, communication, and organizational skills
•          Energetic and curious with a passion for quality and value in health care
•          Computer Proficiency
•          Minimum of five (5) years’ experience in the practice of Cardiology is preferred
•          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