Currently seeking a Board-Certified Orthopedic or Physical Medicine and Rehabilitation physician to participate in pre-authorization and quality improvement solutions for high-tech diagnostic imaging and musculoskeletal management. 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 high-tech diagnostic imaging and other musculoskeletal management solutions.
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 clinically appropriate alternative treatments, studies and sites of care to ordering providers when applicable
Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered modalities.
Actively participate in physician team meetings.
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, 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) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.
MUST have an IL license
Board Certification in Orthopedic Surgery by American Board of Orthopedic Surgery; or in Physical Medicine and Rehabilitation by the American Board of Physical Medicine and Rehabilitation.
Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills