Medical Director – Clinical Reviews
Point32Health
part-time
Posted on:
Location Type: Remote
Location: Remote • Massachusetts • 🇺🇸 United States
Visit company websiteSalary
💰 $229,685 - $344,528 per year
Job Level
Lead
About the role
- Perform clinical review of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical necessity review for all lines of business
- Communicate with providers, provider groups, facilities, and others as necessary to obtain information and resolve clinical issues and concerns
- Support the provider inquiry process for peer-to-peer discussions
- Perform clinical review of expedited and standard appeals for all lines of business
- Provide physician expertise and input for provider payment disputes
- Participate in biannual inter-rater reliability exercises
- Perform Quality of care reviews for Occurrences and Grievances
- Assist with credentialing reviews for providers and facilities
- Participate in staff meetings and relevant committees as requested by supervisor
- Assist with oversight of delegated entities at the request of supervisor
- Assist with creating and developing departmental policies as needed
- Assist with regulatory requirements including external and internal audits and monitoring
- Other projects and duties as assigned.
Requirements
- Current unrestricted license as a medical or osteopathic doctor.
- Board-Certified MD or DO in one of the American Board of Medical Specialties.
- For the Behavioral Health Specialty, American Board of Psychiatry and Neurology Board-Certified MD or DO in Psychiatry.
- Five years of clinical experience.
- Utilization management, quality and / or management experience, at another health plan or at a local provider unit, medical group, or health care facility.
- Skills to communicate with and educate Point32Health peers as well as Tufts Health Plan or Harvard Pilgrim Health Care participating physicians and other providers in a collegial manner.
- An understanding of the principles of utilization management and quality assurance.
Benefits
- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits to support career development, individual & family health, and financial health
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical reviewmedical necessity reviewprior authorizationutilization managementquality assurancecredentialing reviewsappeals managementprovider payment disputesbiannual inter-rater reliabilityquality of care reviews
Soft skills
communicationcollaborationproblem-solvingeducational skillsinterpersonal skillsleadershiporganizational skillsteam participationconflict resolutionpolicy development
Certifications
unrestricted medical licenseBoard-Certified MDBoard-Certified DOAmerican Board of Medical Specialties certificationAmerican Board of Psychiatry and Neurology certification