Medical Reviewer

• Responsible for support and assistance for all cardiology administrative and clinical utilization management and quality improvement functions.
• Acts as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.
• Responsible for clinical conversations with providers and their office staff regarding medical necessity decisions.
• Responsible for maintaining and operating the Guideline Directed Medial Therapy including communicating with offices recommendations regarding medical therapy.
• Responsible for communicating need for additional clinical information to ordering providers.
• Responsibility for prepping cases which cannot be approved and which the provider will not modify or withdraw for P2P discussions with one of the cardiologists.
• Responsible for coordinating with UM staff to ensure timely and accurate communication of clinical decisions.
• Responsible for completion of UM projects and participation in site visit reviews.
• Respect and maintain HIPAA confidentiality guidelines.
• Responsible for maintaining availability to clinical and non-clinical administrative staff during performance of initial and second level screening.
• Acts as an interdepartmental liaison between all New Century Health offices, departments, and committees.
• Serve as subject matter expert and participate in meetings as assigned with practices and/or payers.
• Will work with the Director of UM to ensure client satisfaction.
• Perform all peer clinical review activities while located in a state or territory of the United States.
• Acts with honor and integrity, serving as a role model for the company.
• Performs other duties as assigned.

Clinical Reviewer, Nurse Practitioner/Physician Assistant – Interventional Cardiology

Clinical Reviewer, Nurse – Medical Oncology

Medical Reviewer II

RN – Medical Claims Reviewer

QHCP Clinical Reviewer – NP, PA, CNM