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Medical Director-Radiation Oncology Specialist
1 week ago
Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Our team works across specialties and primary care, connecting the pieces of a fragmented healthcare system to ensure people receive the same level of care and compassion we would want for our loved ones.
Our Culture
We believe that people do their best work when supported to live their best lives. That's why diversity and inclusion are core to our business. We value collaboration, continuous learning, and work-life balance, providing a meaningful way to make a difference in patients' lives in a non-clinical environment.
The Role
You will be a key member of the utilization management team as a Field Medical Director – Rad/Onc. As a FMD, you will serve as the Physician match reviewer in Radiation Oncology and imaging cases that do not initially meet applicable medical necessity guidelines. You will discuss determinations with requesting physicians or ordering providers within the regulatory timeframe, provide clinical rationale for standard and expedited appeals, and utilize medical/clinical review guidelines to assure consistency in the MD review process.
Responsibilities
- Serve as the Physician match reviewer in Radiation Oncology and imaging cases that do not initially meet the applicable medical necessity guidelines.
- 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.
- Aid and act as a resource to Initial Clinical Reviewers.
- Ensure 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.
- Participate in ongoing training per inter-rater reliability process.