Physician Reviewer

Physician Pivot; New York (NY); Sur place; USD 127 000 - 168 000; Plein temps

Résumé du poste

VNS Health is seeking a physician to oversee utilization management for its New York members. You will provide medical determinations, consult on coverage decisions, and ensure timely, guideline-based patient care.

Collaboration with internal teams and external partners is essential. The role requires medical licensure in the state, board certification in Internal or Family Medicine preferred, and a track record in managed care.

Qualifications

• Licensed to practice medicine in state of residence required.
• New York State license preferred.
• Board certification in Internal or Family Medicine preferred.

Responsabilités

• Provide medical determinations for Utilization Management (UM) and internal appeals decisions.
• Review clinical information against evidence-based guidelines and CMS guidance.
• Ensure decision deadlines are met and compliant with regulations.
• Participate in interdisciplinary rounds and collaborate with internal/external partners.
• Provide case summaries and rationale; complete peer-to-peer consultations as required.
• Review Quality of Care concerns and assist with case summaries and next steps.
• Perform other duties as assigned.

Connaissances

Strong communication

Critical thinking

Decision making

Influential skills

Formation

Medical degree

Board certification preferred

Description du poste

Oversees the utilization of medical care and treatment of VNS MSO members and provides direction and guidance to the staff to assure appropriate and expedient decision-making with attention to quality of care. Consults and cooperates with internal and external partners. Works under general direction.

• Provides medical determinations for purposes of Utilization Management (UM), initial and internal appeals decisions. This includes review of clinical information provided against evidence-based guidelines, ensure plan compliance with regulatory requirements, focus on improving quality of care, and support departments of VNS MSO that request medical review services.
• Reviews internal staff or external provider rationales related to coverage decisions.
• Reviews relevant medical records and clinical information on file in the context of performing clinical reviews. (e.g.: inpatient hospital records, outpatient professional notes, Letters of Medical Necessity (LOMN), assessment reports, etc.)
• Utilizes appropriate, evidence-based guidelines for reviews and organizational determination such as. (e.g.: Medicare NCDs, LCDs, Medicaid guidelines, MCG guidelines, VNS Health policies, etc.)
• Provides clinical case summary and determination rationale and member letter verbiage as appropriate.
• Ensures decisions deadlines are met and adhere by business goals and ensure compliance.
• Completes and documents peer-to-peer consultation according to policy through completion of any finalized decision.
• Participates in interdisciplinary rounds.
• Reviews Quality of Care (QOC) concerns, care records and QOC summary. Assist with case summary, case level assignment and recommended next steps.
• Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications:

• Licensed to practice medicine in state of residence required
• Licensed to practice medicine in New York State preferred
• Specialty Board Certified or Eligible required
• Board Certification in Internal or Family Medicine preferred
• Certification in Geriatric Care preferred

Education:

Medical Degree required

Work Experience:

• Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required
• Prior Experience In Geriatric Medicine Preferred
• Prior experience in Utilization Management (UM) and/or a Medical Services Organization preferred
• Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required

Strong Communication And Influential Skills Required

Exceptional critical thinking and decision-making skills preferred

Pay Range

USD $91.72 - USD $122.28 /Hr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.