Seeking a Board-Certified Oncologist and/or Hematologist to participate in pre-authorization and quality improvement solutions for our oncology and diagnostic imaging solutions. Physician Reviewers determine the medical necessity of outpatient requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
**Perform physician-level case review, following initial nurse review, of oncology and high-tech diagnostic imaging requests.
**Determine medical necessity of requests using Clinical Appropriateness Guidelines and client-specific health plan medical policy
**Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care regarding studies and site of service.
**Suggest alternative treatments, studies and sites of care to ordering providers when appropriate
**Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered oncology and diagnostic imaging modalities.
**Actively participate in physician team meetings.
**Demonstrate and maintain knowledge of relevant policies and regulations pertaining to medical oncology and imaging modalities.
**Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines
Perform first level provider appeals of coverage decisions.
**Obtain additional state licensure based upon state regulations and health plan needs
Current unrestricted medical license(s) to practice medicine as a Doctor of Medicine or Doctor of Os
Board Certification in Medical Oncology or Hematology by American Board of Internal Medicine.
Demonstrated knowledge of current practice standards in specialty
Computer literacy with the ability to learn new applications