Participate in pre-authorization and quality improvement solutions for for radiation therapy and related radiology requests. Determine the medical necessity of outpatient requests using clinical appropriateness guidelines and health plan medical policy. Responsibilities include:
**Perform physician-level case review of radiation therapy procedures and related radiology studies
**Determine medical necessity of requests using Clinical Appropriateness Guidelines and client-specific health plan medical policy
**Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care radiation treatments, related radiology studies and sites of care
*Suggest alternative treatments, studies and/or sites of care to ordering providers when appropriate
**Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of radiation therapy procedures and related radiology studies
**Actively participate in physician team meetings.
**Demonstrate and maintain knowledge of relevant policies and regulations pertaining to radiation therapy and related radiology studies
**Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines
**Perform first level provider appeals of coverage decisions.
**Obtain additional state licensure based upon state regulations and health plan needs
Must have Current unrestricted medical license(s) to practice medicine in Illinois and/or California as a Doct
Active Board Certification in Radiation Oncology by American Board of Internal Medicine
Demonstrated knowledge of current practice standard
Must be available for at least 26 hours Monday thru Friday 9-5 For part time roles
Must be available M-F 40 hours for full time.
Opportunity to be set up in a home office after initial training period.
Position is eligible for a competitive base salary with bonus, 401k plan, vacation, PTO, health benefits, CME credits and many other perks.
Must reside in the Chicago area.