Clinical Benefits Physician Advisor

ForHealth Consulting at UMass Chan Medical School; Westborough (MA); On-site; USD 130,000 - 180,000; Full time

Job summary

ForHealth Consulting at UMass Chan Medical School is seeking a Physician Advisor to review applicant medical records and determine eligibility for benefits and long-term care services according to clinical guidelines. The role provides clinical guidance to reviewers and supports quality improvement initiatives.

The ideal candidate is Board certified or eligible in their specialty with at least five years of direct patient care experience and strong problem solving and decision-making skills.

Qualifications

• Board eligible or certified in applicant's specialty.
• Minimum of 5 years of direct patient care experience.
• Proven ability to plan and prioritize work to meet objectives.
• Excellent problem solving and decision making capabilities.

Responsibilities

• Review applicant medical records and determine eligibility for benefits and/or long term care services based on clinical guidelines.
• Review medical records and approve/deny recommendations by Registered Nurse Reviewers.
• Advise on functional capability of applicants based on comprehensive record review.
• Contribute to quality improvement initiatives within the program or department.
• Participate in quality team case reviews.
• Interpret applicable regulations and contribute to clinical policies and quality evaluations.
• Develop and propose alternatives to address issues on a case-by-case basis.
• Participate as a member of clinical or case review teams.
• Train new Physician Advisors.

Skills

Clinical decision making

Prioritization

Problem solving

Communication

Education

Board certification in specialty

Job description

General Summary Of Position

Under the general direction of the Medical Director, Director, or designee, the Physician Advisor is responsible for reviewing applicant medical records and making a clinical determination of eligibility for applicants seeking benefits and/or long term care services based on clinical guidelines. The Physician Advisor also provides clinical guidance reviewers and quality improvement initiatives as appropriate.

General Summary Of Position

Under the general direction of the Medical Director, Director, or designee, the Physician Advisor is responsible for reviewing applicant medical records and making a clinical determination of eligibility for applicants seeking benefits and/or long term care services based on clinical guidelines. The Physician Advisor also provides clinical guidance reviewers and quality improvement initiatives as appropriate.

Major Responsibilities

• Responsible for determining whether an individual applying for and/or receiving public assistance benefits/services meets specific clinical and functional criteria outlined in federal and state regulations
• Review medical records, approves or denies recommendations made by Registered Nurse Reviewers regarding the status of an applicant or member
• Participates in and advises review team regarding the functional capability of an applicant based upon a comprehensive review of all records
• Contributes to quality improvement initiatives developed within the program or department
• Participates in quality team case reviews
• Collaborate with department leadership in the interpretation of all applicable regulations, development of clinical policies and quality evaluations, and provide feedback to clinical staff regarding clinical policies and the outcomes of quality evaluations
• Evaluates and develops alternatives to address problems and issues as they arise on a case by case basis
• Participates as a member of clinical or case review teams
• Responsible for training new Physician Advisors
• Performs other duties as assigned.
  
  

Required Qualifications

• Board eligible or certified in area of specialty
• Minimum of 5 years of experience in direct patient care
• Proven ability to plan and prioritize work in order to meet position objectives or job responsibilities
• Excellent problem solving and decision making capabilities
  
  

The University of Massachusetts Chan Medical School welcomes all qualified applicants and complies with all state and federal anti-discrimination laws.