|An excellent opportunity with a leading $40B healthcare system to conduct utilization reviews and impact quality of care for their members. We are seeking a Board-Certified Neuro surgeons to participate in pre-authorization and quality improvement solutions for high-tech diagnostic imaging and musculoskeletal management. Physician Reviewers determine the medical necessity of outpatient requests using clinical appropriateness guidelines and health plan medical policy. Opportunities can be part time or full time and can be remote after an initial training onsite.
Board-Certified Neurologic Surgeons will participate in pre-authorization and quality improvement solutions for musculoskeletal procedures involving the spine, and high-tech diagnostic imaging. Physician Advisors determine the medical necessity of requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
Determine medical necessity of requests using applicable clinical criteria, which may include Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines and CMS Coverage Determinations, as applicable.
Perform physician-level case review of musculoskeletal utilization requests involving the spine and high-tech diagnostic imaging following initial clinical review by a physical therapy reviewer or a nurse reviewer.
Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service.
Discuss clinically appropriate alternative surgical and non-surgical treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
Provide education regarding applicable clinical criteria.
Perform first level provider appeals of coverage decisions.
Demonstrate and maintain knowledge of applicable clinical criteria and relevant policies pertaining to utilization review.
Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to musculoskeletal services and procedures.
Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal diagnoses, treatments and management.
Actively participate in physician team meetings.
Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.
Obtain additional state licensure based upon state regulations and health plan needs.
. Skills and Certifications [note: bold skills and certification are required]
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification in Neurologic Surgery by the American Board of Neurologic Surgery or (more)
American Osteopathic Board of Neurosurgery.
3-5 years of clinical practice experience past fellowship training is desirable.
Independent performance of standard neurosurgical spine procedures.
Extensive spine surgery experience is desirable.