Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking a Medical Reviewer.
Primary Responsibilities: - Under the general direction of the Vice President of Clinical Affairs, performs medical case review of services subject to approval under the Connecticut Medical Assistance Program (CMAP).
- Participates and contributes actively in medical matters related to utilization management, case management, peer review, quality improvement and other processes requiring medical/clinical leadership and consultation.
- Responds to inquiries from providers, internal stakeholders, and Department of Social Services as necessary.
- Serves as a resource to CHNCT clinical staff.
- Provides recommendations for improving care delivery and health outcomes for CMAP enrollees.
- Participates in activities specific to contractual requirements such as Fair Hearings, etc.
Tasks Performed: - Appropriately documents case review findings, actions, and outcomes in keeping with established policies.
- Collaborates with clinical staff to implement clinical and quality management programs and initiatives.
- Interacts with providers and vendors regarding clinical care and services for CMAP enrollees.
- Actively participates and contributes in medical review team meetings; participates in design and development of care programs and quality improvement initiatives as requested.
Essential Functions: - Engages in telephonic case review and discussion with providers.
- Proactively shares resources, information and guidelines related to quality, cost-effective health care delivery.
- Shares best practices with other Medical Reviewers, CHNCT clinical staff.
- Applies performance data to guide interactions and inform discussions with stakeholders.
- Maintains a high level of productivity; adheres to ASO contract standards regarding timeliness of reviews and appeals.
- Consistently meets plan interrater reliability guidelines.
- Required to attend Medical Reviewer Staff Meetings via phone or in person unless vacation, illness or other extenuating circumstances that prevents the Medical Reviewer to attend these meetings.
- Required to be available for all training/retraining sessions via phone or in person unless vacation, illness or other extenuating circumstances that prevents the Medical Reviewer to attend these meetings. Note: training and retraining sessions may vary from year to year depending on assessment and need.
- Required to attend all mandatory training provided by DSS.
- Must comply with completing all company required trainings.
Desired Education: Medical School
Desired Degree: Medical Doctor or Doctor of Osteopathy
Desired Major: Primary care specialty
Desired Job Experience: Minimum 2 years as a Medical Reviewer or physician consultant in a managed care company preferred. Experience in Utilization Management, Case and Disease Management, preferably with Medicaid populations. Clinical experience in managing a range o1 pathologies and populations and up-to-date knowledge of evidence-based medical guidelines and accepted standards of care for managing the treatments, procedures, conditions, and diseases under review by CHNCT.
Other Qualifications: M.D. or D.O. current, non-restricted Connecticut license andBoard certification. Flexible and able to adapt to altered work processes, technologies, and directives.
Certifications Required: Physician; Surgeon
CHNCT Offers Great Benefits:- Medical, dental and vision coverage options
- Flexible spending and health savings accounts
- Group term life insurance
- A 401(k) plan with company-match and immediate vesting
- Voluntary accidental injury coverage
- Tuition reimbursement and continuing education opportunities
- A generous paid-leave bank and company holidays
- Wellness program
