ChenMed

Physician Reviewer

• Provides Delegated UM by covering the specified territories as assigned: Establish 2-3 cases a day for each market covered (up to 6 markets);
• ensures attendance on all health plan and local calls;
• calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories.
• Advises other physician reviewers.
• Other duties as assigned and modified by manager.

Licensed Physician Reviewer – Dermatology

• Provides Delegated UM by covering the specified territories as assigned
• Establish 2-3 cases a day for each market covered (up to 6 markets)
• Ensures attendance on all health plan and local calls
• Calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories
• Advises other physician reviewers
• Other duties as assigned and modified by manager

Licensed Physician Reviewer – Otorhinolaryngology (ENT) PRN

• Provides Delegated UM by covering the specified territories as assigned: Establish 2-3 cases a day for each market covered (up to 6 markets);
• Ensures attendance on all health plan and local calls;
• Calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories.
• Advises other physician reviewers.
• Other duties as assigned and modified by manager.

Licensed Physician Reviewer – Pulmonology

Licensed Physician Reviewer – Infectious Disease

• Provides Delegated UM by covering the specified territories as assigned
• Establish 2-3 cases a day for each market covered (up to 6 markets)
• Ensures attendance on all health plan and local calls
• Calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories
• Advises other physician reviewers
• Other duties as assigned and modified by manager.

Licensed Physician Reviewer – Rheumatology

• Provides Delegated UM by covering the specified territories as assigned: Establish 2-3 cases a day for each market covered (up to 6 markets)
• ensures attendance on all health plan and local calls
• calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories
• Advises other physician reviewers
• Other duties as assigned and modified by manager

Licensed Physician Reviewer – Endocrinology

• Provides Delegated UM by covering the specified territories as assigned: Establish 2-3 cases a day for each market covered (up to 6 markets)
• Ensures attendance on all health plan and local calls
• Advises other physician reviewers
• Other duties as assigned and modified by manager

Licensed Physician Reviewer – Orthopedics

• Provides Clinical Appropriateness Reviews by covering the specified territories as assigned
• Establish 2-3 cases a day for each market covered (up to 6 markets)
• Ensures attendance on all health plan and local calls
• Calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories
• Advises other physician reviewers
• Other duties as assigned and modified by manager

Licensed Physician Reviewer – Neurology

• Primary physician reviewer for Utilization Management (UM) cases in the organization
• Advising other physician reviewers and attending daily calls with health plan teams
• Assisting with care coordination for patients
• Participating in Process and Quality improvement in Delegated Utilization Management area
• Establishing 2-3 cases a day for each market covered (up to 6 markets)
• Ensuring attendance on all health plan and local calls
• Calling in for weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories
• Other duties as assigned and modified by manager

Licensed Physician Reviewer – Radiology

• Primary physician reviewer for Utilization Management (UM) cases in our organization
• Advise other physician reviewers
• Attend daily calls with health plan teams and local teams assisting with this function
• Coordinate care for patients
• Participate in Process and Quality improvement in Delegated Utilization Management
• Establish 2-3 cases a day for each market covered (up to 6 markets)
• Ensure attendance on all health plan and local calls
• Call in for weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories

Licensed Physician Reviewer – Urologist

• Be the primary physician reviewer for Utilization Management (UM) cases in our organization
• Advise other physician reviewers and attend daily calls with health plan teams
• Coordinate care for patients
• Establish 2-3 cases a day for each market covered (up to 6 markets)
• Ensure attendance on all health plan and local calls
• Participate in Process and Quality improvement in Delegated Utilization Management

Licensed Physician Reviewer, Ophthalmology

Call Center Representative

• Responsible for outbound and inbound customer service call handling related to patient scheduling, general inquiries, and service call interactions
• Providing excellent customer service during each interaction to support better patient health
• Following up with patients to ensure service satisfaction
• Escalating issues/concerns as appropriate
• Maintaining business relationships by providing prompt and accurate service
• Collaborating with team members across multiple departments to promote VIP customer service

Service Team Coordinator – Call Center

Pharmacist

• Works to ensure that ChenMed members have access to all medically necessary prescription drugs
• Completes prior authorizations for internal expert peer discussions on high-cost medications
• Involved in formulary management and clinical pharmacy services
• Reviews coverage determinations and appeals in a timely, compliant, and accurate manner
• Acts as a liaison between ChenMed and its patients with respect to the clinical guidelines we practice
• Serves as the formulary expert for the therapeutic class they are reviewing
• Develops, implements and maintains pharmacy cost control and quality initiatives
• Contributes to projects aimed at improving STAR ratings, HEDIS, CAHPS, and other quality metrics

Clinical Review Pharmacist

• Reviews coverage determinations and appeals in a timely, compliant, and accurate manner.
• Ensures compliance with the coverage determination and appeals process.
• Acts as a liaison between ChenMed and its patients with respect to the clinical guidelines we practice.
• Serves as the formulary expert for the therapeutic class they are reviewing.
• Contributes to projects aimed at improving STAR ratings, HEDIS, CAHPS, and other quality metrics.
• Assists with clinical questions and phone calls from prescribers, pharmacies and/or ChenMed members.
• Develops, implements and maintains pharmacy cost control and quality initiatives under the direction of leadership and guidelines.
• Monitors drug utilization and assists Pharmacy leadership team in understanding quality and cost control issues.
• Acts as a liaison between ChenMed and its members with respect to the pharmacy benefits.
• Works with providers to ensure accurate coverage determination decisions.
• Performs outreach to patients and providers as part of quality and/or cost control initiatives.
• Performs other duties as assigned and modified at manager’s discretion.