Urology Physician Clinical Reviewer

3 weeks ago


Frankfort, Kentucky, United States Evolent Health Full time

Evolve Your Career with Evolent Health

Evolent Health partners with health plans and providers to achieve better outcomes for people with complex and costly health conditions. As a Physician Clinical Reviewer, you will be a key member of our utilization management team, making a meaningful difference in patients' lives in a non-clinical environment. Enjoy better work-life balance on a team that values collaboration and continuous learning while providing better health outcomes.

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.

Discuss determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provide clinical rationale for standard and expedited appeals.

Utilize 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.

Requirements:

MD/DO/MBBS degree 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

Strong clinical, management, communication, and organizational skills required

Energetic and curious with a passion for quality and value in health care required

What We Offer:

Competitive hourly rate of $95-110

Bonus component dependent on pre-defined performance factors

Comprehensive benefits, including health insurance benefits, to qualifying employees

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. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance.



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