Otolaryngologist-Physician Reviewer-Radiology (Full-Time)

What You’ll Be Doing

• 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.
• Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals.
• Utilizes 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.
• Aids and acts as a resource to Initial Clinical Reviewers.
• Ensures documentation of all communications with medical office staff and/or MD provider is recorded 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.
• Participates in on-going training per inter-rater reliability process.

Qualifications

• MD/DO/MBBS 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.

Technical Requirements

• We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router.

Benefits

As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.