Board-Certified Pain Management Physicians will participate in pre-authorization and quality improvement solutions for interventional pain management procedures involving the spine, and high-tech diagnostic musculoskeletal imaging. Physician Advisors determine the medical necessity of requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
- Determine medical necessity of requests using applicable clinical criteria, using Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines and CMS Coverage Determinations, as applicable.
- Perform physician-level case review of interventional pain management utilization requests involving the spine such as epidural injections (interlaminar/caudal and transforaminal), epidural adhesiolysis, facet joint injection, radioablation, regional sympathetic nerve block, sacroiliac joint injections, spinal cord stimulators and thermal intradiscal procedures following initial clinical review by a physical therapy reviewer or a nurse reviewer.
- Perform physician-level case review of interventional pain management utilization requests involving musculoskeletal high-tech diagnostic imaging following initial clinical review by a physical therapy reviewer or a nurse reviewer.
- Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to interventional pain management treatments, imaging and appropriate sites of service.
- Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
- Provide education regarding applicable clinical criteria.
- Perform first level provider appeals of coverage decisions.
- Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to interventional pain management services and procedures.
- Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal diagnoses, treatments and management.
- Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.
- Obtain additional state licensure based upon state regulations and health plan needs.
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification in Pain Management by the American Board of Anesthesiology
The American Board of Psychiatry and The American Board of Neurology or the American Board of Physical Medicine and Rehabilitation
At least 6 + years of clinical practice experience past fellowship training is desirable.
Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment