Our client is currently seeking Physician Case Reviewers to conduct office-based pre-authorization of high-tech diagnostic imaging, cardiac testing, specialty pharmacy and sleep management services. Physician Reviewers determine the medical necessity of outpatient requests using clinical guidelines and health plan medical policy.
Successful candidates will:
Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging, modalities. Imaging modalities include CT, CTA, MRI, MRA, PET, and Nuclear Cardiology.
- Determine medical necessity of requests using Medical Necessity Guidelines and client-specific health plan medical policy
- Conduct peer-to-peer discussions with ordering physicians, physician assistants, and nurse practitioners to provide education regarding established guidelines and accepted standards of care as they pertain to the use of diagnostic imaging studies, cardiac testing, specialty pharmacy and sleep management services.
- Suggest alternatives services to ordering providers when appropriate
- Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application
- Demonstrate and maintain current knowledge of modalities and new applications of known technologies for diagnostic imaging, cardiac services, specialty pharmacy and sleep management
- As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered modalities.
- Participate in periodic physician reviewer meetings
- Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of diagnostic imaging procedures, cardiac services, specialty pharmacy, radiation therapy, and sleep management.
- Acquire, demonstrate, and maintain proficiency with ICD-9 and CPT coding.
- Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert
- Perform first level provider appeals as designated by the client for adverse determinations
- Obtain additional state licensure based upon business needs
- Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
- Board Certification by American Board of Medical Specialties
- Demonstrated knowledge of current practice standards in specialty
- Strong oral communication and interpersonal skills
- Computer literacy with the ability to learn new applications
- Strong analytical skills
- Ability to multi-task
- Ability to work both independently and in a team environment
- Ability to work in a dynamic, fast-paced environment