We’re also tackling the social determinants of health by creating non-clinical partnerships in the communities where we work and live, because everyone should have access to quality health care. We use innovative tools and approaches to help members get the most out of their plan benefits, as affordably as possible. We are more than a health care insurer and we are truly anchored in our purpose: to do everything in our power to stand by our members in sickness and in health.
BASIC FUNCTION: This position is responsible for assigned aspects of medical policies and programs. Performs medical reviews and interacts with the provider communities for assigned areas.
- Complete medical necessity prepayment, pre-certification and other claim reviews as required by applicable State and Federal regulations, statute or accreditation requirements.
- Complete peer to peer conversations regarding member plan of care as required by applicable State and Federal regulations, statute, or accreditation requirements.
- Assist in the ongoing activities of utilization review, care/case management, and cost containment programs for assigned lines of business to ensure the consistency and cost effectiveness of review procedures.
- Maintain effective liaison with the other areas of Health Care Management to ensure cooperation with quality and utilization initiatives.
- Devise plans for outcome studies and provides direction to participants.
- Work effectively with appropriate company areas in enhancing HCSC compliance with all application regulations and industry standards such as HIPPA, HEDIS, etc.
- Devise and review statistical reports relating to patterns of care on hospital utilization and practice patterns of physicians. Determine recommendations for follow-up procedures.
- Provide physician clinical expertise to other corporate areas.
- Develop external relationship and liaison with physicians, organized hospital administrators and medical service companies that will enhance the corporate image and serve as a means for providing education and resolving utilization review issues. Represent the corporation at various state and national medical association meetings as required.
- Provide educational assistance to medical providers in the effective control of expenditures of health care dollars through effective utilization review and cost containment while improving the quality of health care.
- Keep appropriate supervisory Medical Management informed of pertinent developments and perform special assignments as required. Assist in the development, implementation and administration of corporate medical policies.
- Must be located in a state or territory of the United States when conducting medical necessity review or peer to peer conversation for the purpose of Utilization management.
- Communicate and interact effectively and professionally with co-workers, management, customers, etc.
- Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
- Maintain complete confidentiality of company business.
- Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
- Physician with a current and unrestricted physician license in a state or territory of the United States.
- Maintain Board Certification as a M.D. or D.O. (by a specialty board approved by the American Board of Medical Specialties (doctors of medicine); or the Advisory Board of Osteopathic Specialists (doctors of osteopathic medicine)
- 5 years of clinical experience
- Analytical and communication skills
- Strategic thinking skills
* 3 years Managed Care experience highly preferred