Medical Claims Processor Jobs in Rochester, NY (NOW HIRING)

Job Description:

Summary:

This position assists the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. This role supports the HARP line of business.

Essential Accountabilities:

Level I

• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers.
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Oversees the activities of physician advisors. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
• Develops alliances with the provider community through the development and implementation of the medical management programs. May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues, as needed. Represents the business unit at appropriate state committees and other ad hoc committees
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Reviews medical literature and applies evidence-based principles using high proficiency skills for a broad range of clinical services.
• Reviews internal trend reports to assess present and future needs and opportunities.
• Interacts with regulatory and accreditation agencies as assigned.
• Provides clinical support to the Sales and Marketing divisions
• Provides clinical leadership for the implementation of new utilization/case/quality management initiatives

Minimum Qualifications:

Level I

• Current New York State licensed physician.
• Minimum 5 years of experience in a BH managed care settings or BH clinical setting (at least 2 of which are in a clinical setting).
• Board certification in general psychiatry or certification in addiction medicine or certification in the subspecialty of addiction psychiatry.
• Appropriate training and expertise in general psychiatry and/or addiction disorders.
• Ability to identify, analyze and resolve complex medical issues.
• Skills in evidence-based medicine.
• Strong interpersonal skills essential for communication to staff at all levels of the organization.,
• Basic skill sets in electronic communication systems such as e-mail and Word.

Level II (in addition to Level I Minimum Qualifications)

• Superior evidence-based medicine skill set
• Strong interpersonal skills essential for communication to physicians in the community.
• Strong verbal presentation skills to lead internal and external discussions at board levels
• Advanced skill sets in electronic communication systems such as e-mail, Word, PowerPoint, and Excel.

Physical Requirements:

• Works from a desk most of the time.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

$202,000.00 - $303,000.00

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.