CARDIOLOGY PHYSICIAN CLINICAL REVIEWER
Company: Evolent Health
Location: Montgomery
Posted on: October 25, 2024
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Job Description:
Your Future Evolves HereEvolent partners with health plans and
providers to achieve better outcomes for people with most complex
and costly health conditions. Working across specialties and
primary care, we seek to connect the pieces of fragmented health
care system and ensure people get the same level of care and
compassion we would want for our loved ones.Evolent employees enjoy
work/life balance, the flexibility to suit their work to their
lives, and autonomy they need to get things done. We believe that
people do their best work when they're supported to live their best
lives, and when they feel welcome to bring their whole selves to
work. That's one reason why diversity and inclusion are core to our
business.Join Evolent for the mission. Stay for the culture.What
You'll Be Doing:As a Cardiology, Physician Clinical Reviewer you
will be a key member of the utilization management team. We can
offer you a meaningful way to make a difference in patients lives,
in a non-clinical environment. You can enjoy better work- life
balance on a team that values collaboration and continuous learning
while providing better health outcomes.Collaboration
Opportunities:Routinely interacts with leadership and management
staff, other Physicians, and staff whenever a physician`s input is
needed or required. As well as, aids and acts as a resource to
Initial Clinical Reviewers.What You Will Be Doing:Serve as the
specialty match reviewer in Cardiology cases, that do not initially
meet the applicable medical necessity guidelines, as well as other
requests when providers, clients, or state laws require specialty
reviews to be completed by the subject matter expert.Provides
clinical rationale for standard and expedited appeals.Discusses
determinations (peer to peer phone calls) with requesting
physicians or ordering providers, when available, within the
regulatory timeframe of the request.Utilizes medical/clinical
review guidelines and parameters to assure consistency in the MD
review process to reflect appropriate utilization and compliance
with SBU`s policies/procedures, as well as Utilization Review
Accreditation Commission (URAC) and National Committee for Quality
Assurance (NCQA) guidelines.Ensures documentation of all
communications with medical office staff and/or MD provider is
recorded in a timely and accurate manner.Participates in on-going
training per inter-rater reliability process.May assist the Senior
Medical Director in research activities/questions related to the
Utilization Management process, interpretation, guidelines and/or
system support.On a requested basis, may function as Medical
Director for selecting health plans or regions, assuming overall
accountability for utilization management while working in
conjunction with the Senior Medical Director.Qualifications -
Required and Preferred:MD/DO/MBBS DegreeCurrent, unrestricted
clinical license in medicine or required specialtyObtaining and
maintaining medical licenses in the state you reside, as well as,
other state licensure required per business needsActive Board
Certification in Cardiology, Vascular Surgery or Adult Congenital
Heart DiseaseStrong clinical, management, communication, and
organizational skillsEnergetic and curious with a passion for
quality and value in health careComputer ProficiencyMinimum of five
(5) years' experience in the practice of Cardiology is preferredNot
under current exclusion or sanction by any state or federal health
care program, including Medicare or Medicaid, and is not identified
as an "excluded person" by the Office of Inspector General of the
Department of Health and Human Services or the General Service
Administration (GSA), or reprimanded or sanctioned by Medicare.No
history of a major disciplinary or legal action by a state medical
boardTechnical Requirements:We require that all employees have the
following technical capability at their home: High speed internet
over 10 Mbps and, specifically for all call center employees, the
ability to plug in directly to the home internet router. These
at-home technical requirements are subject to change with any
scheduled re-opening of our office locations.Evolent is an equal
opportunity employer and considers all qualified applicants equally
without regard to race, color, religion, sex, sexual orientation,
gender identity, national origin, veteran status, or disability
status. If you need reasonable accommodation to access the
information provided on this website, please contact
recruiting@evolent.com for further assistance.The expected base
salary/wage range for this position is $115-$130/hr. This position
is also eligible for a bonus component that would be dependent on
pre-defined performance factors. As part of our total compensation
package, Evolent is proud to offer comprehensive benefits
(including health insurance benefits) to qualifying employees. All
compensation determinations are based on the skills and experience
required for the position and commensurate with experience of
selected individuals, which may vary above and below the stated
amounts.Don't see the dream job you are looking for? Drop off your
contact information and resume and we will reach out to you if we
find the perfect fit!For more insights about Evolent Health, click
on Life At Evolent (https://www.evolent.com/) to learn more!
Keywords: Evolent Health, Montgomery , CARDIOLOGY PHYSICIAN CLINICAL REVIEWER, Healthcare , Montgomery, Alabama
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