01Key Responsibilities
Case Review: Conduct regular reviews to monitor the appropriateness of care provided to beneficiaries and recommend any necessary interventions or adjustments need to align with CMS National and Local Coverage Determinations (NCD/LCD)Peer to Peer Prior Authorization discussions: Prepare for and participate in peer-to-peer discussions with providers and suppliers to review clinical documentation, discuss coverage criteria, and address questions related to prior authorization requests.Training & Education: Assist in the training and development of clinical teams on CMS NCD/LCD guidelines, clinical documentation and compliance.Clinical Guidance: Provide recommendations for improvements in clinical practices based on findings from record reviews, data analysis, and best practices in the field.Quality Improvement: Participate in the development and implementation of quality improvement initiatives to enhance care delivery and achieve CMS performance goals.Documentation: Maintain accurate and up to date records of all clinical reviews, audits and quality improvement efforts. Your Schedule:Training & Onboarding (First 23 Weeks)Training will occur MondayFriday from 8:00 AM to 5:00 PM CT and will include onboarding, shadowing, workflow education, and hands-on case review training. After Completion of Training:Following successful completion of training, team members will transition to a production schedule of MondayFriday, 8:00 AM to 5:00 PM PT, as the current business operations are aligned to the Pacific Time Zone.Each shift will be 9 hours in length, which includes one hour of dedicated break time. Specific schedules may be adjusted based on operational needsRequired Qualifications:Be a board-certified clinician, including a Doctor of Medicine or a Doctor of Osteopathy identified by an individual NPI in a specialty recognized by the American Board of Medical Specialties Anesthesiologists or those with a completed fellowship in pain management are strongly preferred OR be associated with a primary specialty designation that aligns with PMR, neurology, pulmonology, urology, or orthopedics.Board certified for at least 3 years;Currently hold an active, valid and unrestricted license to practice medicine in at least one U.S. state, territory, or the District of Columbia. Must not be excluded from participating in Medicare, Medicaid or the Childrens Health Insurance Program.State of Washington license to practice medicine preferred or willingness to obtain.Utilization management experience preferred.Skills:Excellent communication skills (both verbal and written) with the ability to collaborate effectively with diverse healthcare teams.Familiarity with electronic health records (EHR) and documentation and coding practices (ICD-10, CPT)Knowledge of CMS regulations and Medicare requirements.Strong attention to detail and organizational skills to manage multiple tasks and prioritiesAbility to work in a fast paced, deadline driven environmentNote:Primarily remote with occasional on-site requirements.Occasional travel may be required for team meetings and onsite reviews.KEYWORDS: Physician; MD .
