Medical Reviewer

Community Health Network of Connecticut, Inc.•Wallingford, CT

1d•$174,400 - $249,200

About The Position

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking a Medical Reviewer. This role involves performing medical case review of services subject to approval under the Connecticut Medical Assistance Program (CMAP), participating in medical matters related to utilization management, case management, peer review, and quality improvement. The Medical Reviewer will serve as a resource to CHNCT clinical staff, provide recommendations for improving care delivery and health outcomes, and participate in activities specific to contractual requirements such as Fair Hearings.

Requirements

M.D. or D.O. current, non-restricted Connecticut license
Board certification
Flexible and able to adapt to altered work processes, technologies, and directives.
Physician
Surgeon

Nice To Haves

Minimum 2 years as a Medical Reviewer or physician consultant in a managed care company preferred.
Experience in Utilization Management, Case and Disease Management, preferably with Medicaid populations.
Clinical experience in managing a range of pathologies and populations and up-to-date knowledge of evidence-based medical guidelines and accepted standards of care for managing the treatments, procedures, conditions, and diseases under review by CHNCT.

Responsibilities

Performs medical case review of services subject to approval under the Connecticut Medical Assistance Program (CMAP).
Participates and contributes actively in medical matters related to utilization management, case management, peer review, quality improvement and other processes requiring medical/clinical leadership and consultation.
Responds to inquiries from providers, internal stakeholders, and Department of Social Services as necessary.
Serves as a resource to CHNCT clinical staff.
Provides recommendations for improving care delivery and health outcomes for CMAP enrollees.
Participates in activities specific to contractual requirements such as Fair Hearings, etc.
Appropriately documents case review findings, actions, and outcomes in keeping with established policies.
Collaborates with clinical staff to implement clinical and quality management programs and initiatives.
Interacts with providers and vendors regarding clinical care and services for CMAP enrollees.
Actively participates and contributes in medical review team meetings; participates in design and development of care programs and quality improvement initiatives as requested.
Engages in telephonic case review and discussion with providers.
Proactively shares resources, information and guidelines related to quality, cost-effective health care delivery.
Shares best practices with other Medical Reviewers, CHNCT clinical staff.
Applies performance data to guide interactions and inform discussions with stakeholders.
Maintains a high level of productivity; adheres to ASO contract standards regarding timeliness of reviews and appeals.
Consistently meets plan interrater reliability guidelines.
Required to attend Medical Reviewer Staff Meetings via phone or in person unless vacation, illness or other extenuating circumstances that prevents the Medical Reviewer to attend these meetings.
Required to be available for all training/retraining sessions via phone or in person unless vacation, illness or other extenuating circumstances that prevents the Medical Reviewer to attend these meetings.
Required to attend all mandatory training provided by DSS.
Must comply with completing all company required trainings.