Medical Peer Reviewer

HealthFirst • New York, NY

1d

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. Responsibilities may be adjusted based on changing needs of the organization.

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

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
• Ensures compliance to internal Healthfirst and external regulations.
• 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

Benefits

• Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements).

What This Job Offers

• Job Type: Part-time
• Education Level: Ph.D. or professional degree