A major medical management company is seeking
- Be part of the industry leader in providing intelligent utilization and diagnostic solutions to improve
- Enjoy a predictable work schedule.
- No night, weekend, holiday or on-call work is required.
- Work remotely from home or relocate to one of their many onsite locations
Responsibilities include but are not limited to:
- Provide timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
- Review appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated.
- Provide timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions.
- Document all actions related to clinical review sessions and attests to appeal review qualifications as required.
- Maintain files of all reviews as required by law and Health Plans to retrieve reportable data.
- Maintain necessary credentials and immediately informs eviCore of any adverse actions relating to medical licenses and/or board certifications.
- Support the annual review of utilization review criteria.
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