Minimum Experience Required
- The successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in a clinical specialty recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18months).
- Have at least 5 years of clinical experience (post residency/fellowship
- Knowledge of applicable state and federal laws, URAC and NCQA standards a plus, and familiarity with automated processes and computer applications and systems is required.
- Provides timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
- Reviews appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated.
- Provides timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions.
- Documents all actions related to clinical review sessions and attests to appeal review qualifications as required.
- Maintains files of all reviews as required by law and Health Plans to retrieve reportable data.
- Maintains necessary credentials and immediately informs eviCore of any adverse actions relating to medical licenses and/or board certifications.
- Supports the annual review of utilization review criteria.
- Supports and communicates eviCore policy and procedures to the provider community.
- Participates in strategic planning for and evaluation of the Care Management process/unit.
- Assists with staff educational training and in-service programs and serves as a clinical resource for eviCore staff.