Prior Approval Reviewer (Physician)

State of Illinois • Springfield, MO

12d • Hybrid

About The Position

The Department of Healthcare and Family Services, Bureau of Professional and Ancillary Services is seeking to hire a motivated candidate to serve as a Prior Approval Reviewer. Under the direction of the Prior Approval and Customer Relations section manager, this position will serve as a specialized physician reviewer for the Medical Review Unit. The duties for this position may include but are not limited to; providing expert medical/clinical, consultative, program and policy advisory services related to specialized medical equipment and services to staff, convening regular meetings with staff to participate in developing, implementing and maintaining system changes or policy decisions that may impact medical services to individuals eligible for Medical Assistance, and participate in developing medical criteria options for program coverage of durable medical equipment, supplies and other covered services. The ideal candidate will have strong communication skills, excellent team leadership skills, ability to thrive in a high volume and fast paced environment and demonstrate the ability to collaborate with team members to ensure operations are running effectively. HFS values employees with different backgrounds, life experiences, and talents. Employees receive a robust benefit package including: Monday-Friday work schedule Flexible work schedules are available in many program areas. (Remote work may be an option for certain positions.) Health, Life, Vision, and Dental Insurance Pension Plan Paid Parental Leave Deferred Compensation Program and other pre-tax benefit programs (Medical/Daycare) Employees earn (12) paid Sick Days annually. New Employees earn (10) paid Vacation Days their first year of service and can earn up to (25) paid Vacation Days annually. Employees earn (3) paid Personal Days annually. (13-14) paid holidays annually (based on start date) At the Illinois Department of Healthcare and Family Services (HFS), we value staff as our greatest asset. We work in a spirit of teamwork to help millions of Illinoisans access high quality healthcare and fulfill child support obligations to advance their physical, mental, and financial well-being. We provide healthcare coverage for children and adults through Medicaid and other medical programs, and we help ensure that children receive financial resources from both their parents through Child Support Services. The HFS Office of the Inspector General investigates, audits and reviews program activity to ensure the integrity of our programs is maintained. HFS is committed to promoting and preserving a workplace culture that embraces diversity, equity, and inclusion. We welcome and value employees with different backgrounds, life experiences, and talents. It is the collective sum of our individual differences that provides a broad perspective, leading to greater innovation and achievement. In recruiting for our team, we recognize the unique contributions of each applicant regardless of culture, ethnicity, race, national origin, sex, gender identity and expression, age, religion, disability, and sexual orientation. HFS is an equal opportunity employer.

Requirements

• Requires an Illinois license to practice medicine
• A minimum of two (2) years of experience making clinical prior approval decisions including, working with complex medical data, and familiarity with medical coding such as ICD-10CM, CPT or HCPCSs
• A minimum of two (2) years of professional experience communicating with medical providers on behalf of a payer regarding billing codes and rejection codes as well as medical terminology
• Requires two (2) years of experience working with Medical Management Information Systems (MMIS) or similar medical processing system
• Requires completion of a background check and self-disclosure of criminal history
• Requires the ability to utilize and maintain state issued equipment such as a laptop
• Requires ability to attend seminars, conferences, and trainings to stay current on methods, tools, ideologies, or other industry related topics relevant to the job duties

Nice To Haves

• A minimum of two (2) years of experience making clinical prior approval decisions including, working with complex medical data, and familiarity with medical coding such as ICD-10CM, CPT or HCPCSs
• A minimum of two (2) years of professional experience communicating with medical providers on behalf of a payer regarding billing codes and rejection codes as well as medical terminology
• A minimum of two (2) years of experience working with Medical Management Information Systems (MMIS) or similar medical processing system
• A minimum of two (2) years of experience utilizing the basic principles and practices of general medicine and surgery, including the diagnosis and treatment of diseases and inquiries
• A minimum of two (2) years of experience conducting research regarding recent changes to technology or accepted procedures in the field of general medicine to recommend modifications to policies
• A minimum of two (2) years of experience evaluating the quality of medical care and treatment for a medical or social services organization
• A minimum of two (2) years of experience performing reviews of medical data and determining medical needs for a medical or social service organization
• A minimum of two (2) years of experience preparing detailed and accurate medical documentation to support any medical review determination

Responsibilities

• Serves as a Prior Approval Reviewer for the Bureau of Professional & Ancillary Services/Prior Approval & Customer Relations Section/Medical Review Unit
• Conducts clinically based research on new technology and medical advancements related to specialized medical equipment and services and makes recommendations on modifications to current policy and expansion of program coverage
• Conducts clinical analysis of medical procedures and diagnosis coding changes
• Provides expert testimony on behalf of the department, including, but not limited to, fraud and abuse cases and participant appeals on denials of coverage
• Stays abreast of new techniques and procedures in the clinical/medical field
• Performs other duties as required or assigned which are reasonably within the scope of the duties enumerated above

Benefits

• Health, Life, Vision, and Dental Insurance
• Pension Plan
• Paid Parental Leave
• Deferred Compensation Program and other pre-tax benefit programs (Medical/Daycare)
• 12 paid Sick Days annually
• 10 paid Vacation Days their first year of service and can earn up to 25 paid Vacation Days annually
• 3 paid Personal Days annually
• 13-14 paid holidays annually (based on start date)

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed