Medical Peer Reviewer NY Licensed M.D. or D.O. Part Time Remote

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations.

Responsibilities

Assess/review requests for authorization and claims payment based on medical records and internal Healthfirst information; Render determinations in the format and within timeframes to follow Regulatory and Operational policies; Maintain productivity standards; Collaborate with Utilization Management and Care Management and medical departments as needed; Manage cases/caseload from multiple lines of businesses; Demonstrate ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities; Complete mandatory Company compliance training and training in new systems and software; Enter each day's hours worked in Workday; Perform other duties as assigned

Requirements

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; Annual Compliance and other training as assigned; Annual Inter-Rater Reliability (IRR) Testing; Complies with the Healthfirst Conflict of Interest Policy for Professionals

Nice to have

Board Certified in Internal Medicine, Family Practice, Emergency Medicine; 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

Benefits

Paid Time Off (PTO); Holiday pay and straight hours worked; Medical, dental and vision coverage; Incentive and recognition programs; Life insurance; 401k contributions