Physician Reviewer (20 hours/wk) at BMC HealthNet Plan in Boston, Massachusetts

Job Description:

Physician Reviewer (20 hours/wk)

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The Physician Reviewer will support the staff of the Office of Clinical Affairs in the areas of medical management including daily case review, as well as evaluation of medical policy, utilization trend management, quality, appeals and grievances, and pharmacy reviews.

Key Functions/Responsibilities:

• Provides clinical case review, consultation and oversight for all utilization management activities.


• Conducts review of prior authorizations, concurrent reviews and retrospective reviews that do not meet standard criteria and determines coverage.


• Works with the Medical Director of Utilization Management to identify appropriate us of InterQual criteria and Medical Policy.


• Works with the Medical Director to ensure consistent medical decision making for all physician reviewers, including the contracted physicians.


• Conducts clinical review of appeals and grievances.


• Develops and supports clinical initiatives to support department quality improvement and utilization management goals.


• Collaborates with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities and initiatives to improve the health of the population, the quality and experience of care our members receive, and lower the overall cost of care at the population level.


• Participates in and chairs clinical committees as assigned by the Medical Director of Utilization Management.


• Supports quality, and pharmacy committees and activities.


• Provides input to the strategic planning process for the Office of Clinical Affairs as requested.


• Represents the Chief Medical Officer in Massachusetts, New Hampshire and other locations as requested.

Qualifications:

Education:

• Graduate as a Medical Doctor from an accredited college of medicine is required.

Experience:

• 8-10+ years of related experience is required including a minimum of 5 years direct clinical experience and a minimum of 3 years experience in medical management in a managed care setting.

Certification or Conditions of Employment:

• Board certification in recognized medical specialty.


• Current unrestricted licensure as an MD.


• Current unrestricted licensure as an MD in the Commonwealth of Massachusetts is preferred.

Competencies, Skills, and Attributes:

• Excellent demonstrated clinical skills and knowledge.


• Excellent written and verbal communication skills.


• Comprehensive knowledge of accrediting organizations such as NCQA.


• Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.


• Knowledge of Medicare and state Medicaid regulations, guidelines, and standards.


• Proven leadership skills and relationship building.


• Knowledge of managed care principles and processes.


• Ability to work independently with intermittent supervision.


• Adhere to appropriate turn-around-times and deadlines while maintain results of high quality and reliability.

Working Conditions and Physical Effort:

• Ability to travel to locations within New Hampshire and Massachusetts.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.