Physician Reviewer _ Remote
- Expired: over a month ago. Applications are no longer accepted.
SUMMARY OF RESPONSIBILITIES:
Works collaboratively with the Specialty Program Medical Director and Clinical Operations Team to deliver the right care to the right patient at the right time
Key member of the utilization management team, supporting the clinical review of ordering provider procedure and/or surgical requests as managed within a given Specialty Program
Provides timely review of service requests that do not initially meet applicable medical appropriateness guidelines
Routinely interacts with ordering providers, physician reviewers, leadership and program management, as well as clients, when needed
REQUIRED UTILIZATION MANAGEMENT FUNCTIONS:
Provides timely review of specialty program authorization requests that do not meet current evidence-based medicine guidelines and cannot be resolved in initial clinical reviews.
Outreaches to and discusses clinical rationale with ordering providers, as appropriate.
Follows clinical review and evidence-based medicine guidelines to assure consistency in the specialty program case review processes.
Reflects appropriate utilization and compliance with HealthHelp policies/procedures, as well as URAC and NCQA guidelines.
Documents clinical reasoning and rationale for all case determinations.
Advises Specialty Program Medical Director of any additional areas of clinical opportunity or operational efficiencies.
Maintains necessary credentials and immediately informs HealthHelp of adverse actions relating to medical licensure or board certifications.
Degree from an accredited school of medicine
Current, active, unrestricted license to practice medicine in a state or territory of the United States
Board certified specialist and actively practicing specialty in the United States
Meets HealthHelp credentialing requirements
Preferred but not required:
Experience or familiarity with principles and procedures of utilization management in managed care
Excellent negotiation, leadership, and communication skills
Ability to support flexible working hours
Academic affiliation, preferred but not required
Physicians Reviewers needed in the following specialty:
HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.
Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.
WNS Global Services Inc. (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities. Globally, the group’s over 44,000+ Professionals serve across 60 delivery centers in 16 countries worldwide.
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