Job DescriptionProvides clinical program leadership and develops, implements and approves policies within recognized area of responsibility.- Develop and maintain medical policy. Establish rationale for approving inquires and appeals.
- Assists with clinical research, writing documents, and documenting decisions.
- Provide utilization management for prior authorization procedures. Review cases and make decisions based on medical policy.
- Provide clinical support to various areas of the organization. Process requests for clarification, interpretation, or questions about policy or benefits. Review potential impacts of clinical matters.
- Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
- Perform clinical reviews and conduct peer to peers.
- Participate in JUMP committee meetings.
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Qualifications"
- Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
- Seven (7) years clinical practice experience.
- Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.
- Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.
- Proven leadership, problem solving, and the ability to manage multiple priorities.
- Strong teaching and communication skills.
- Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
- Demonstrated skill with Microsoft Office Suite and web-based programs.
- Understanding of health plan functions related to utilization, care, and quality management.
- Other related skills and/or abilities may be required to perform this job.
Department Summary / Preferences:
Specialty Care Knowledge is preferred.
Medical Policy Experience is a plus.
