Physician Clinical Reviewer
3 weeks ago
Evolent Health partners with health plans and providers to achieve better health outcomes for individuals with complex and costly health conditions.
Our team works across specialties and primary care to connect the pieces of the fragmented healthcare system, ensuring people receive the same level of care and compassion we would want for our loved ones.
We believe that people do their best work when they're supported to live their best lives and feel welcome to bring their whole selves to work.
As a result, diversity and inclusion are core to our business.
You'll enjoy a better work-life balance on a team that values collaboration and continuous learning, while providing better health outcomes.
Routinely interacts with leadership and management staff, other physicians, and staff when a physician's input is needed or required.
As a Physician Clinical Reviewer in Neurology, you'll serve as the reviewer for imaging cases that don't meet medical necessity guidelines, as well as other imaging requests that require specialty reviews.
You'll discuss determinations with requesting physicians or ordering providers, providing clinical rationale for standard and expedited appeals within the regulatory timeframe.
You'll utilize medical/clinical review guidelines and parameters to ensure consistency in the MD review process, reflecting appropriate utilization and compliance with Evolent Health's policies/procedures, as well as URAC and NCQA guidelines.
You'll ensure documentation of all communications with medical office staff and/or MD providers is recorded in a timely and accurate manner.
You may assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support.
Participates in ongoing training per inter-rater reliability process.
Requirements:
- 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
- Energetic and curious with a passion for quality and value in healthcare - Required
- Computer Proficiency - Required
- Not under current exclusion or sanction by any state or federal healthcare 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
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.
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 Health is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees.
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