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Urology Physician Clinical Reviewer
2 months ago
Evolent Health is seeking a skilled Physician Clinical Reviewer to join our team. As a key member of our utilization management team, you will play a critical role in ensuring that patients receive the best possible care.
Key Responsibilities- Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.
- Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals.
- 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.
- Aids and acts as a resource to Initial Clinical Reviewers.
- Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.
- May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
- MD/DO/MBBS- Required
- Minimum of five (5) years' experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years- Preferred
- Current, unrestricted clinical license in medicine or required specialty- Required
- Obtaining and maintaining medical licenses in the state you reside, as well as, any license required per business needs- Required
- Active Board Certification Urology (If a specialty or subspecialty, must also have that BC)- Required
- Strong clinical, management, communication, and organizational skills- Required
- Energetic and curious with a passion for quality and value in health care- Required
- Computer Proficiency- Required
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.
Evolent Health 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.
As part of our total compensation package, Evolent Health is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees.
