In this role you would initially have a training time of 8-10 months in office then be transitioned into a home office.
Ideal Candidate Experienced clinical practitioner who would like to transition to a non-patient-facing clinical environment. Excellent interpersonal skills with the ability to work with provider physicians in a peer-to-peer conversation.
Conduct office-based pre-authorization of high-tech diagnostic imaging, cardiac testing, and specialty pharmacy and sleep management services. Physician Reviewers determine the medical necessity of outpatient requests using clinical guidelines and health plan medical policy.
**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 Clients 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-10 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
Skills and Certifications:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine Board Certification by American Board of Medical Specialties
Board Certification by American Board of Medical Specialties Demonstrated knowledge of current practice
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment