Medical Peer Reviewer

Requirements

• Licensed M.D. or D.O. or D.M.D. or D.D.S.
• Board Certified in a specialty recognized by the American Board of Medical Specialties
• -Board Certified in Internal Medicine , Family Practice, OBGYN, Emergency Medicine
• -Previous, relevant experience in utilization management and clinical practice
• -Knowledge of Medicare, Medicaid, and MLTC plans
• -Time management, critical thinking, communication, and problem-solving skills
• -Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
• -Knowledge of member satisfaction/incident management and regulations
• -Knowledge of quality improvement methodologies
• Compliance & Regulatory Responsibilities : Ensures compliance to internal Healthfirst and external regulations.
• Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
• Annual Inter-Rater Reliability (IRR) Testing
• Complies with the Healthfirst Conflict of Interest Policy for Professionals
• Know Your Rights
• All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthf

Benefits

Additional Information

Job Profile Summary A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations. Duties/Responsibilities: -The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. -The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies. - The Medical Peer Reviewer will: -Maintain productivity standards. - Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses -Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed -Complete mandatory Company compliance training and training in new systems and software. -Enter each day's hours worked in Workday, on the same day. -Perform other duties as assigned -Responsibilities may be adjusted based on changing needs of the organization. Weekday Requirements: -The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage - The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday. -Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked -The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy. Weekend Requirements: - Each Medical Reviewer is required to be primary coverage one weekend a month - Each Medical Reviewer is required to be available as back up, if needed, one weekend a month - Dental Reviewers have a fixed schedule

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