Healthfirst

Duties//Responsibilities:

• The Medical Peer Reviewer will assess//review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
• The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies.
• The Medical Peer Reviewer will: 
• Maintain productivity standards.
• Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases//caseload from multiple lines of businesses
• Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members//internal medical departments as needed
• Complete mandatory Company compliance training and training in new systems and software.
• Enter each day’s hours worked in Workday, on the same day.
• Perform other duties as assigned
• Responsibilities may be adjusted based on changing needs of the organization.

  Weekday Requirements:

  • The Medical reviewer requires 25 hours a week of coverage//5 days per week.
  • Each Medical Reviewer will cover one legal holiday //year and will be compensated Holiday pay and straight hours worked
  • The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy.

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    Weekend Requirements:

    • Each Medical Reviewer is required to be primary coverage one weekend a month
    • Each Medical Reviewer is required to be available as back up, if needed, one weekend a month .

       Minimum Qualifications:

      Licensed M.D. or D.O. or D.M.D. or D.D.S.

      Board Certified in a specialty recognized by the American Board of Medical Specialties

       

      Preferred Qualifications:

      • New York State Board Certified in Internal Medicine or Family Practice
      • Previous, relevant experience in utilization management and clinical practice
      • Knowledge of Medicare, Medicaid, and MLTC plans
      • Time management, critical thinking, communication, and problem-solving skills
      • Knowledge of UM//QM case philosophies and reporting requirements to state and federal agencies
      • Knowledge of member satisfaction//incident management and regulations
      • Knowledge of quality improvement methodologies

         

        Compliance & Regulatory Responsibilities:

        Ensures compliance to internal Healthfirst and external regulations.

        • Licensed M.D. or D.O. or D.M.D. or D.D.S.
        • Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
        • Annual Inter-Rater Reliability (IRR) Testing
        • Complies with the Healthfirst Conflict of Interest Policy for Professionals