Family Medicine-Physician Reviewer-Field Medical Director, Radiology (Full-Time

About the role

Evolent partners with health plans and providers to achieve better outcomes for people with complex and costly health conditions. Our mission is to connect the pieces of the fragmented healthcare system and ensure people receive the same level of care and compassion as they would for their loved ones.

Responsibilities

• Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.
• Discuss determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provide clinical rationale for standard and expedited appeals.
• Utilize medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU’s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.
• Aid and act as a resource to Initial Clinical Reviewers.
• Absorb and document all communications with medical office staff and/or MD provider in a timely and accurate manner.
• May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
• Participate in on-going training per inter-rater reliability process.

Qualifications

• MD/DO/MBBS with a minimum of five (5) years experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years is preferred.
• Current, unrestricted clinical license in home state medicine or required specialty- Obtaining and maintaining medical licenses in the state you reside, as well as, any license required per business needs.
• Active Board Certification by an accredited organization.
• Strong clinical, management, communication, and organizational skills.
• Energetic and curious with a passion for quality and value in health care.
• Computer proficiency.

Benefits

Comprehensive benefits (including health insurance benefits) are offered to qualifying employees as part of Evolent’s total compensation package.

Pay

The expected base salary/wage range for this position is $95-96/hr.

Schedule

Details on the schedule are not specified in the job posting.