Cardiology Physician Clinical Reviewer

4 weeks ago

Albany, United States Evolent Health Full time

Your Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. What You’ll Be Doing: As a Cardiology, Physician Clinical Reviewer you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes. Collaboration Opportunities: Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required. As well as, aids and acts as a resource to Initial Clinical Reviewers. 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 - Required and Preferred: 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, Vascular Surgery or Adult Congenital Heart Disease 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 Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance. The expected base salary/wage range for this position is $115-$130/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit

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