Ancora Search is working with a leading specialty health care benefit management company that has a distinct operating model to deliver a collaborative, non-denial-based approach to utilization management. The company is growing and looking to hire four Medical Director, Physician Reviewers for Radiology.
The Medical Director, Physician Reviewer - Radiology works collaboratively with the Senior Medical Director - Radiology and clinical operations team to deliver the right care to the right patient at the right time.
Provide timely review of image authorization requests that cannot be resolved at a nurse-level.
Outreach to and discuss clinical rationale with ordering physicians.
Consistently reinforce and utilize clinical review guidelines and processes to reflect appropriate utilization and compliance with internal and customer policies and procedures, as well as to URAC and NCQA guideline standards.
Deliver clinical case determinations based on HealthHelp’s guidelines and current medical evidence base.
Document all actions related to clinical review sessions and attest to appeal review qualifications as required.
Maintain files of all reviews as required by law and Health Plans to retrieve reportable data.
Mandatory participation in all onboarding training protocols.
Mandatory participation in ongoing program and performance-related meetings.
Collaborate with Medical Director on case review performance and promote recommended improvements.
Advise Medical Director of any additional area of clinical opportunity or operational efficiencies.
Maintain necessary credentials and immediately informs HealthHelp of adverse actions relating to medical licensure or board certifications.
5+ years of active practice
Excellent negotiation, leadership, and communication skills
Ability to work in a fast-paced, evolving environment
Strong interpersonal skills at both individual and team level
Experience or familiarity with principles and procedures of utilization management in managed care
Ability to support flexible working hours
Experience and familiarity with government programs
Telecommuting is allowed.
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