REMOTE Physician Reviewer

PSG Global Solutions; Nashville (TN); Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a Clinical Expert to provide support for Medicare Supplement and Individual Supplemental Health Insurance products. This role involves collaborating with various departments including Underwriting, Legal, and Marketing to ensure strategic project delivery. You will lead a multi-disciplinary team, providing clinical resources and education, while also working closely with actuarial teams to maintain clinical integrity. If you are passionate about improving healthcare delivery and have a strong clinical background, this is an exciting opportunity to make a significant impact in the industry.

Qualifications

• Strong clinical expertise in Medicare and Supplemental Health products.
• Experience in underwriting and claims processes.

Responsibilities

• Provide clinical expertise for Medigap and SHL products across departments.
• Oversee the Supplemental Benefits Clinical Team and ensure project delivery.

Skills

Clinical Expertise

Underwriting Knowledge

Claims Processing

Fraud Detection

Cost Analysis

Education

Bachelor's Degree in Nursing or related field

Clinical Certification

Tools

Data Analysis Tools

Clinical Management Software

Job description

Description

1. Provides clinical expertise and support for all departments and divisions related to the clients Medicare Supplement (Medigap) and Individual Supplemental Health and Life (SHL) Insurance products, including but not limited to, Underwriting, Legal, Marketing, Operations, Product, and Claims.
2. Has clinical responsibility for helping to ensure the strategic and tactical delivery of project work for our clients Supplemental Health products in forty-nine states and the District of Columbia (DC).
3. Provides clinical resources and education to a multi-disciplinary team of nonclinical staff for CSB, responsible for supporting Medigap underwriters in all aspects of the underwriting process, assists SHL Claims Representatives with complex claims consults, appeals and reviews, rescissions, as well as fraud and abuse cases.
4. Oversees the Supplemental Benefits Clinical Team (SBCT), which is a multifunctional team that includes Medical Directors, pharmacist(s), data analyst(s), and other ad hoc members as needed from across the Enterprise.
5. Works closely with the actuarial team for the clinical integrity of various undertakings, involving underwriting, pricing, claims automation, and cost analysis.
6. Responsible for clinical input to the development of new innovative tactics and methodologies to improve cost containment for Medigap and SHL products, such as Preventive Care, vendor solutions, and other medical management initiatives.