Medical Peer Reviewer

HF Management Services•New York City, NY

11d

About The Position

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations. Duties/Responsibilities: ·The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. ·The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies. · The Medical Peer Reviewer will: ·Maintain productivity standards. · Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses ·Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed ·Complete mandatory Company compliance training and training in new systems and software. ·Enter each day’s hours worked in Workday, on the same day. ·Perform other duties as assigned ·Responsibilities may be adjusted based on changing needs of the organization. Weekday Requirements: ·The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage · The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday. ·Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked ·The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy. Weekend Requirements: · Each Medical Reviewer is required to be primary coverage one weekend a month · Each Medical Reviewer is required to be available as back up, if needed, one weekend a month · Dental Reviewers have a fixed schedule

Requirements

Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties
Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
Annual Inter-Rater Reliability (IRR) Testing
Complies with the Healthfirst Conflict of Interest Policy for Professionals

Nice To Haves

Board Certified in Internal Medicine , Family Practice, OBGYN, Emergency Medicine
Previous, relevant experience in utilization management and clinical practice
Knowledge of Medicare, Medicaid, and MLTC plans
Time management, critical thinking, communication, and problem-solving skills
Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
Knowledge of member satisfaction/incident management and regulations
Knowledge of quality improvement methodologies

Responsibilities

Assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
Render determinations in the format and within timeframes to follow Regulatory and Operational policies.
Maintain productivity standards.
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software.
Enter each day’s hours worked in Workday, on the same day.
Perform other duties as assigned
Responsibilities may be adjusted based on changing needs of the organization.