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Associate Medical Director, Utilization Management Reviewer

4 months ago

Greater Boston Area, United States Cohere Health Full time

Company Overview:

Cohere Health is illuminating healthcare for patients, their doctors, and all those who are important in a patient's healthcare experience, both in and out of the doctor's office. Founded in August 2019, we are obsessed with eliminating wasteful friction that patients and doctors experience in areas that have nothing to do with health and treatment, particularly for diagnoses that require expensive procedures or medications. To that end, we build software that is expressly designed to ensure the appropriate plan of care is understood and expeditiously approved, so that patients and doctors can focus on health, rather than payment or administrative hassles.

Opportunity Overview:

We are looking for physicians who have expertise in general medical topics including medical and surgical clinical areas to deliver on Cohere's program by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines.

Reporting to the Senior Medical Director for Cohere Health, this is a critical role in a company that is rapidly scaling to impact millions of patients. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives.

What You Will Do:

  • Support the clinical content team in reviewing the company's clinical decision guidelines and evidence based literature
  • Provide expert input on content for influencing physicians in medical care to improve the quality of patient outcomes
  • Provide timely medical reviews that meet Cohere's stringent quality and timeliness parameters
  • Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen and knowledge of evidence based literature and medical society guidelines
  • Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision
  • Use correct templates for documenting medical necessity decisions during case review
  • Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research
  • Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers
  • Support projects specific to building the team's clinical expertise and efficiency, as delegated
  • Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated

Your Background and Requirements:

Required:

  • Completed US-based residency program in Internal Medicine or General Surgery
  • Board certification as an MD or DO with a current unrestricted state license to practice medicine - reviewers must maintain necessary credentials to retain the position
  • 5+ years of clinical practice beyond residency/fellowship in Internal Medicine or General Surgery

Preferred:

  • 1+ years of managed care utilization review experience desirable
  • Membership in national and/or regional specialty societies
  • Licensure in AZ, GA, MS, NC, ND, OK, OR, or TX is highly desirable - you should be willing to obtain additional state licenses with Cohere's support

Competencies/Success Factors:

  • Able to multitask and manage tasks to completion on a timely basis and in an organized fashion
  • Excels in a matrix organization
  • Excellent communication - written and spoken
  • Comfortable with technology - willing and able to learn new software tools
  • Understanding of managed care regulatory structure and processes
  • Detail-oriented, flexible, and able to work autonomously with little supervision

We can't wait to learn more about you and meet you at Cohere Health

Equal Opportunity Statement:

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it's personal.

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