This position provides clinical oversight of the Utilization Management program for the Sleep Management and Pulmonary Program at CareCentrix,including utilization review for medical necessity determinations. The physician reviewer provides consultative services to the UM review staff, oversees selection of education for providers, and provides input into the Utilization Management and Quality Improvement programs, This position interfaces with the internal staff, CareCentrix network providers, ordering physicians , and client payers as required,
Attributes / Qualifications
This position requires excellent written and verbal communication, with the ability to interface effectively with all levels of staff, including ordering physicians, internal and external clinical review teams, and high level executive leadership representatives. This position requires flexibility, and ability to prioritize work in a fast paced environment to assure compliance with regulatory and accrediting agency requirements. This position requires experience and knowledge of utilization management principles, and of regulatory and accreditation standards of utilization review. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Required Education / Experience
Must be an MD or DO, with an active and unencumbered medical license, in the states specific to the CareCentrix client payer account rules, which may require multiple state licenses to be held concurrently. Must have appropriate specialty board certifications, specific to the CareCentrix program for which he/she consults (Sleep Medicine and Pulmonology) Minimum of 5 years experience in clinical practice, and prefer at least 3 years experience with managed care programs or care delivery networks. Should have expertise in specific clinical fields, including current knowledge on best practices and new technology, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers.